Transcript Susan Kammerle PPT

Care Management of a
Population: Focus on Asthma
CHOP Care Network Chestnut Hill
7700 Germantown Ave
Philadelphia, PA 19118
Sue Kammerle RN,CPN
We are coordinating care by having systems in
place to accomplish our Practice Goals
• Decrease asthma hospitalizations of our patients
• Decrease acute episodes (hospital, office based, urgent care) of our
patients
• Improve functional measures of well being (school attendance, sleep,
participation in desired activities) of our patients
• Improved our patients and families perception of control and knowledge of
disease
• To incorporate evidence based practices within all clinical decisions
• To develop an infrastructure that imbeds clinical goals into workflow and is
sustainable
• To develop workflows that are efficient and fiscally sound
Risk Stratification
The National Asthma Education and
Prevention Program
Expert Panel Report 3: Guidelines for the Diagnosis and
Management of Asthma
August 2007
Clinical Care System – Evidenced Based Care
Snapshot -- defining diagnosis “language”
http://www.nhlbi.nih.gov/guidelines/asthma/
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High Risk Patients
• Care Manager receives referral from primary clinician regarding patient
who has asthma which is NOT in control, not based on severity. Patient
may have had multiple exacerbations, ER visits or hospitalizations.
• Care Manager may identify patients from ER or Hospitalization Review and
recommend need for Care Coordination to provider
• Focus of telephone contacts are to identify reasons for non adherence to
recommended treatments and asthma care plan. Care Manager then will
provide appropriate education and/or resources needed to improve
adherence focusing on the goal of keeping asthma symptoms IN
CONTROL.
• Communicates with primary clinician regarding contacts with family
through copying telephone encounters and focused discussion on
planning future interventions.
• May refer to community resources, such as LaSalle Neighborhood Nurses
as needed to make home visits.
Clinical Care System - Asthma
Standard Care / Planned Care / Evidence Based Care
Our sites attempted to standardize care throughout the practice -- goal to keep it simple

All asthma patients should have a diagnosis on the active problem list
 intermittent, mild, moderate, severe
 asthma NOS, asthma intrinsic, asthma exacerbation, EIA, etc . are not to be
used on Problem list

All asthma patients should have an active prescription (developed order templates
aligned with agreed standards).
 a short acting bronchodilator
 an inhaled steroid for all with a Persistent Diagnosis (mild, moderate, severe)
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Clinical Care System - Asthma
Standard Care / Planned Care / Evidence Based Care
Snapshot designed with critical information
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Clinical Care System - Asthma
Standard Care / Planned Care / Evidence Based Care
Our sites attempted to standardize care throughout the practice -- goal to keep it simple

All patients with an asthma diagnosis should receive an annual flu vaccine (annual
EMR mining with follow-up planned calls).

All patients with a Asthma Diagnosis should have an active Asthma Care Plan.

Frequency of Asthma encounters (planned /follow-up encounters)
 1 year from last WCC visit for those with an intermittent asthma diagnosis.
 6 months from last WCC or last “asthma assessment encounter” for those
with a mild persistent asthma diagnosis
 4 months from last WCC or last “asthma assessment encounter” for those
with a moderate persistent asthma diagnosis
 3 months from last WCC or last “asthma assessment encounter” for those
with a severe persistent asthma diagnosis
 1 month or less for uncontrolled asthma
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Clinical Care System - Asthma
Standard Care / Planned Care / Evidence Based Care
Our sites attempted to standardize care throughout the practice -- goal to keep it simple
Recommended medications
 Ventolin HFA - recommended short acting bronchodilator (counter, on all
formularies)
 Spacers with all mdi’s recomended
 Flovent HFA - recommended inhaled steroid for all patients with a persistent
asthma diagnosis (dosing 2 puffs BID with spacer)
 Flovent 44 - mild persistent asthma
 Flovent 110 - moderate persistent asthma
 Flovent 220 - severe persistent asthma
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Office Based Education
OBJECTIVE: To implement the EPR-3 guidelines
by providing clinicians and support staff
appropriate training in the pathophysiology,
diagnosis, treatment guidelines and
educational goals for patients and their
families
Methods for providing staff education
 Monthly scheduled business meetings for
providers included discussion of guidelines
 Scheduled presentations for clinicians, nurses and
support staff by office based nurse practitioners
and consultants
 Two nurse practitioners in our office have become
Certified Asthma Educators and can provide on to
one in house review of guidelines, curriculum,
mentoring for patient education to clinicians,
nurses and medical assistants
Resources
Expert Panel Report 3: Guidelines for the Diagnosis and Management
of Asthma (EPR-3)
August 2007
 Association of Asthma Educators Curriculum
www.asthmaeducators.org
 CHOP Patient Communication Focal Points
 CHOP In patient Asthma Teaching Script
 CHOP Patient Family Education Manual Teaching Sheets
 CHOP DVD: “Controlling Asthma, A Guide for Families”
 CAPP, Community Asthma Prevention Program of Philadelphia:
Four Visit Education Plan for the Asthma Prevention Office Visit
 “Culturally –Competent Asthma Education: A Continuing Education
Monograph”, from the Association of Asthma Educators, Maureen
George, MSN, RN, CS
Asthma Care Assistant
Populates in Telephone and Office Encounters
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Triage Nurse Responsibilities
• Refill Encounters of Asthma Medications to
include Assessment of Current Status, Plan is
to use Asthma Control Tool
• Nurses to be looking also at entire patient: Is
medication being refilled too soon? Has
patient been in office for yearly well visit? Has
patient been in office for appropriate follow
up based on asthma diagnosis?
Triage Nurse Responsibilities
• Using Barton Schmitt Protocols and EPIC templates to document
telephone encounter for Acute Symptoms.
• Phone follow up for office visits for exacerbations, ER visits or
Hospitalizations: Clarification of family’s understanding of Asthma Care
Plan including medication and adherence to it or barriers to adherence.
• Make appropriate in office follow up appointment with primary clinician.
• HAS BEEN TARGETED TO ALL PATIENTS WITH ASTHMA, REGARDLESS OF
SEVERITY OR PRIMARY CLINICIAN.
• Protocols exist for ER and Hospital follow-up
Asthma Control Tool
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Clinical Nurses
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Asthma Care Assistant in encounter
ACT on all well visits for patients with asthma
Asthma Education Modules
Consignment of spacers and nebulizer
Patient education handouts
Asthma Care Plans
Identification of Asthma and Highest Risk
Care Coordination Patients
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Patient Education
Linked to patient education material
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Coordination of Highest Risk Patients
• Patient identified in Problem List as Advance Care Planning
• Focus of telephone contacts are to identify reasons for non adherence to
recommended treatments and asthma care plan. Care Manager then will
provide appropriate education and/or resources needed to improve
adherence focusing on the goal of keeping asthma symptoms IN
CONTROL.
• Communicates with primary clinician regarding contacts with family
through copying telephone encounters and focused discussion on
planning future interventions.
• May refer to community resources, such as LaSalle Neighborhood Nurses
as needed to make home visits.
• EMR function has Care Coordination pool-encounters are routed by
providers and nursing staff
• Meet with patient and parents in office for further review of needs.
• Referral staff route encounter to CC when an Advance Care Planning
Patient requests a referral.
Care Coordination
ER visits
• Primary Responsibility of Care Coordinator
• Review all ER reports recieved
• Review all calls to CHOP After Hours for those with disposition of Referred
to ER
• Call parent to follow up, assess current status, medications , and need for
office follow up
• Make note of any needs assessed during phone call such as needs for
education or equipment as a heads up to the clinician and staff seeing
patient in the office for follow up
• Keep encounter active in EMR if unable to reach parent as a reminder that
additional phone calls may be needed.
• Make note in Snapshot of asthma ER and Hospital visits- an easy visual
reminder if has frequent ER visits
• A triage nurse may the the first to receive a call from the parent. They will
do the follow up and then route the call to Care Coordination for further
review.
Care Coordination
Hospitalizations
• Place call to parent while still inpatient
• Notify Primary Clinician and Care Coordination
staff of admission
• Keep encounter active in EMR to follow
patient course
• Place call after discharge to assess current
status, medications and need for office follow
up
In Conclusion
Though Care Coordination within our office we
are working to keep our patients in control
with thorough Assessment, Education,
Intervention and Follow Up.