Statement
of the Problem or Issue
Asthma is a chronic disease and has become a public health epidemic.
The number of people in the U.S. with asthma has doubled in the
past 15 years to an estimated 15 million. Since the early 1980s,
asthma morbidity and mortality have been increasing dramatically
despite advances in medical technology and in the development
of new pharmacologic agents for its treatment. Experts agree that
most of the negative effects of asthma are preventable, however;
recent data from the U.S. Public Health Services shows that this
country falls far short of meetings its asthma goals. While that
National Asthma Education and Prevention Program (NAEPP) established
national guidelines for the diagnosis and management of asthma
and revised and promoted them in 1998, many health centers, particularly
the most stressed safety net providers, have real challenges with
their implementation. Significant asthma disparities in prevalence,
morbidity and mortality exist by race and socioeconomic status,
with African American, low-income residents in Chicago bearing
one of the heaviest asthma burdens in the nation.
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Target Population
The target population for the initiative is the asthmatic patient
population served by the Cook County Bureau of Health Services.
More specifically, two of the Bureau’s three hospitals (John
H. Stroger Jr. Hospital of Cook County and Provident Hospital)
and their asthma specialty centers, and the network of over 30
ambulatory care sites and interested community health centers
located in the most medically fragile areas of the County. The
population is comprised of predominately uninsured and underinsured
residents of Chicago and suburban Cook County.
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Program Design
The ACI was designed to develop primary care teams to champion
care improvements in asthma at their ambulatory sites. The team
began by developing asthma specialty centers into high quality
training centers. County ambulatory sites as well as federally
funded community health centers with high asthma volume are invited
to participate in the initiative. A partnership agreement is made
with the sites to negotiate the amount of time required for teams
to develop the clinical and quality improvement skills needed
to become a “champion.” These teams, typically comprised
of a physician and nurse, are enrolled in an intensive, four-month
clinical rotation, spending one session per week seeing patients
in the asthma clinic. Teams are mentored by pulmonologists, allergists
and asthma nurses. Over time, the champions made a real contribution
to managing the high volume of asthmatics in the specialty centers.
The teams also participate in a chronic care improvement collaborative,
based on the model promoted by the Institute for HealthCare Improvement.
The framework used is the Chronic Care Model, and a rapid cycle
improvement process is taught and tested. Teams are supported
by project faculty and staff in developing measurable objectives
and mobilizing their health care centers to make system wide improvements
to support asthma care consistent with the NAEPP guidelines. A
contract with Northwestern University’s Center for Healthcare
Studies was developed to analyze and present chart audit data
for the participating sites to present at quarterly meetings of
the collaborative. These meetings are used for continuing education
on quality improvement processes, sharing strategies and outcomes,
as well as peer support.
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Program Impact and Outcomes
Clinical competencies were developed by faculty to ensure skills
to enable providers to practice consistently with the NAEPP guidelines.
The following clinical experience was typically sufficient to
achieve the competencies. Nurse champions conduct nursing assessments,
teach peak flow/MDI technique, review action plans, and medication
instructions for 20 patients, as well as provide nursing intervention
for at least 3 patients during an acute asthma exacerbation. Physician/nurse
practitioners champions conduct medical assessments and develop
written treatment plans with 20 patients, follow up with at least
40 patients, and manage at least 3 patients during an acute asthma
exacerbation.
Project faculty and staff developed and reproduced materials for
the centers and participating primary care sites to support providers
in care based on the NHLBI asthma guidelines: asthma action plans
and education brochures at reading level and languages appropriate
for patients, asthma guidelines pocket cards and wall posters
for physician reference, asthma progress note stamp, and demonstration
equipment kits to support patient education.
Participation in the chronic care improvement collaborative required
quarterly chart audits to monitor changes in care over time. Attached
are graphs based on chart audits of a cohort of 9 participating
sites over the course of the first year of the initiative. Several
graphs, for example, indicate significant improvement in the quality
of patient assessment which include: documentation of peak expiratory
flow rate, 10.6% increase; documentation of missed school days
in patients <18 years, 37.4% increase; documentation of daytime
symptoms, 26.9% increase; documentation of unplanned urgent care/hospitalization,
11 %; and documentation of asthma severity based on the NAEPP
guidelines, increase 22.3%. Improvements in self-management support
include, for example, documentation of the use of an action plan
including when to contact provider or EMS, increase 23.6%; documentation
that the patients’ MDI technique was observed, increase
6.8%; documentation that a new or continued inhaled steroid was
prescribed, increase 7%.
Dr.
Lori Riley, a family practice physician from Cook County Englewood
Health Center, participated in the Initiative and stated: “I
had the opportunity to review cases with an adult pulmonologist
and a pediatric allergist for four months. Now, instead of sending
a patient to a specialist right away, I am better able to initiate
a treatment plan. I’m a lot more hands-on, I site and develop
a written action plan and demonstrate how to use the equipment
with patients. I spend a lot more time as an educator and less
as a rescuer.
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Innovation/Creativity
While the project received start up funding from the federal Central
Management Services and the Illinois Department of Public Aid,
the majority of costs for the initiative were absorbed by the
Bureau. The Bureau mobilized its internal training capacity, making
a commitment to bring together both asthma specialist and primary
care providers in a way that uses their time differently, which
develops staff competencies and relationships, and ultimately
improves the system of care for patients with asthma.
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Lessons Learned
A clinical coordinator is an essential part of the quality improvement
process, providing assistance to teams through regular on-site
visits between quarterly meetings of the collaborative. The clinical
coordinator assists with plan-do-study- act cycles, identifies
and provides tangible resources to support the teams, assists
in conducting chart audits for reporting outcomes, and coordinates
quarterly meetings of the collaborative.
Champions need to be mature providers with leadership skills who
can influence the practice of their peers, and help to enlist
the support of their medical and nursing directors/administrators
to enable providers to dedicate the time necessary for the improvement
process to take hold in their health centers.
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