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ASTHMA CARE PROCESS MODEL AND EDUCATION DOCUMENTATION

Karmella Koopmeiners RN MS FNP, Nurse Specialist Primary Childrens Medical Center (PCMC) and Intermountain Healthcare 100 North Mario Capecchi Drive Salt Lake City, Utah 84113 e-mail: karmella.koopmeiners@imail.org

Mission Statement
To Provide Excellent Asthma Care For Children Through Improved Documentation of Education and the Revised CPM
Primary Childrens Medical Center (PCMC) is a 289-bed teaching hospital providing 80% of inpatient services for children. US News and World Report recently ranked it as one of the nations best childrens hospitals, recognizing them in 7/10 pediatric subspecialties. Intermountain Healthcare (IH) Intermountain Healthcare has 22 facilities, 5 of the 9 rural facilities are certified by Medicare as Critical Access Hospitals (4/Utah,1/Idaho). These facilities recognize their stewardship in the community and are committed to sharing information and strive to reduce costs to consumers of healthcare while maintaining the quality of healthcare services

Vision Statements
The asthma team is a multidisciplinary team of health

care professionals committed to providing extraordinary care for pediatric patients. This is accomplished through improved patient and staff education, communication, clinical excellence and evidence-based practice using NHLBI and NAEPP guidelines.
We support a patient/family centered approach;

including self-monitoring tools and participation in asthma care. We promote a collaborative effort across the continuum of care by partnering with primary care for a more proactive, preventative approach to improve the utilization of resources measured by patient outcomes.

Background Information
Incidence- 23 million-9.4% of children, 7.3% of adults Prevalence-only chronic illness-across the age spectrum Impact-disproportionately low-income, American Indian Best Practices NAEPP Guideline #3 patient education Costs- U.S. (2007) Total-19.7 billion 25% or 5 billion preventable by managing symptoms Direct costs-(2010) 1,500 hospital D/C @ $16.2 million, (2009)-7,259 ED visits-$21.9 million = $7.3 million treat-release,$14.7 million treat-admit visits Indirect cost- absenteeism, presenteeism at work/school Return On Investment(ROI) = dollars saved and expenses avoided/ dollars invested
Source: Utah Department of Health (UDOH)

PCMC Asthma Team

Clinical Nurse Specialists (Advanced Practice Nurses) Karmella Koopmeiners, Kate Thompson Data Team -Tanya Stout, Rebecca Baggaley Educators-Rebecca Bawden RN, Brandon Andersen RT Physicians-Bern Fassl-Physician and Project Leader, Bryan Stone, Flory Nkoy-Research Team Leader Research Team Sarah Halbern, Eun Hea Kim, Allison Wilcox RN Respiratory Clinical Expanded Roles (RNs) Anna Pate CMU, Alison Kohutek IMSU, John Mohr RTU Riverton Care Unit Michelle Hofmann, Kristina McKinley, Kim Young RN

Asthma Team Roles and Responsibilities

PROVIDER Pt/family education and documentation of the revised CPM is complete Act as a resource to staff for pt/ family education and CPM guidelines Reviews pediatric questionnaire and completes the medication reconciliation process Completes admission orders including chronic control table Using the revised CPM coordinates the plan of care (POC) with the team Completes discharge orders and discharge instructions (DOADI) with modification in the home management plan of care (HMPC) REGISTERED NURSE Coordinates , provides and documents education and revised CPM documentation Provides education to pt /family based on needs assessment and reinforces medications and skills based on observations Documents education provided and pt/family response to education Reviews pediatric questionnaire with the pt/ family including medication reconciliation and chronic control table Ensure medication reconciliation process is documented and asthma admit orders complete Recommends step-up therapy (change in home management plan) Reviews discharge teaching instructions (DOADI) with the pt/family RESPIRATORY THEARIPST Provides, documents education , assists with CPM completion Provides individual instruction on equipment (i.e., spacer, MDI, peak flow, nebulizer) and other needs unique to the patient /family Reviews patient/family technique and evaluates the return demonstration of skills Reviews needs assessment and completes documentation on the teaching outline Reinforces the concepts taught by the team Assists pt/family with pediatric questionnaire Communicates and collaborates with the team about educational needs of the patient and revised CPM implementation Recommends changes in the home management plan of care (HMPC) CLINICAL EXPANDED ROLE/EDUCATORS Provide clinic expertise in asthma Develops and revises education content and documents (job aides , handouts, schedules etc.) implements, evaluates revised CPM and provides unit staff education Conducts audits of documentation of education, revised CPM and provides feedback to the staff and teams Act as a resource, consultant and liaison with providers and teams for education and revised CPM development and evaluation CLINICAL NURSE SPECIALIST Advanced Practice Nurse leaders in asthma program development (education and CPM) Develops CPM documents (tools, algorithms, scenarios) and develops staff education Resource, consultant, and mentor to multidisciplinary staff Recommends content for pt/family education Facilitator and Nursing Leader for PCMC team Responsible for asthma quality improvement programs, EBP, research and program development across the continuum of care Evaluates asthma data (process and outcome) for patients and teams

Step-Up Therapy, Medication Reconciliation, Chronic Control Table

How does your asthma influence your life?
For Hospital Use Only Review answers and determine the following items for this patient: Age: __________________ Current step for asthma management: ___________ Takes controller 4 or more times a week? YES Takes controller 3 or less times a week? YES Does not take a controller NO NO

1. How often do you or your child have one of the following problems: cough, wheezing, feeling short of breath, chest tightness 2. How often do you or your child wake up from sleep with breathing difficulties or cough? 3. What is your or your childs peak flow level usually? (if recommended by your doctor) 4. How often does asthma limit you or your childs daily activities: playing, running, exercising, or missing school / work? 5. How often do you or your child use a quick relief (rescue) medication (for example albuterol)?

Dont Know Dont Know Dont Know Dont Know Dont Know Dont Know

Twice a week or less Less than or equal to once a month 80% - 100% personal best (green) Never

More than Twice a week More than once a month 50% - 80% personal best (yellow) Some limitation More than Twice a week 2 3 times

Throughout the day

More than once a week Less than 50% of personal best (red) Frequent limitation

Twice a week or less

Several times a day

Degree of chronic control is: ** well controlled ** not well controlled ** poorly controlled

6. In the last year, how often did you or your childs asthma get worse and require oral steroids, a clinic visit, or an ED visit?

0 1 time

Greater than 3 times

Recommendation for change in home management plan? ________________________________________________________________________

What Medication (s) do you or your child take to control your asthma? How many TIMES PER DAY do How many puffs/ nebs do you take per MEDICATION DOSE you take this medication? treatment? If you are taking pills, how NAME many pills do you take each time?
0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 0 1 2 3 4 5 Other 5 Other 5 Other 5 Other 5 Other 1 2 1 2 1 2 1 2 1 2 3 4 5 Other________ 3 4 5 Other________ 3 4 5 Other________ 3 4 5 Other________ 3 4 5 Other________

On average, how many times per week do you take this medication?

1 2 3 4 5 6 7 Other_______ 1 2 3 4 5 6 7 Other_______ 1 2 3 4 5 6 7 Other_______ 1 2 3 4 5 6 7 Other_______ 1 2 3 4 5 6 7 Other_______

As Needed As Needed As Needed As Needed As Needed

1. Admission Orders (paper) 2. Review Questionnaire-a. Med Rec/b. Chronic Control (paper)
c. Recommend Step-Up Therapy (paper) 3. Needs Assessment/Teaching Outline (paper)/Tandem (EMR) Watch Asthma DVD/TV (passive) Review Flipchart (interactive) Consult Respiratory Therapy for skills/special needs

Return Demonstration of Skills/Medication Teaching

Discharge Teaching-DOADI/Help2 (EMR) copy and sign (paper) Process of Education/CPM Documentation (EMR vs. Paper)

Fishbone-Documentation Problems
Define role of RT/ nurses in the educational process Define role of RT/ nurses in the educational process

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Prioritization of Leverage Points

Specific Aim Statement

From January 2011 - March of 2012, sustaining the board goals and improvement in documentation from 71%-85% (stretch) will occur with medication teaching: Sustaining the 2011 Board Goal- 81% Teaching of Triggers- 89% (paper) Medications difference between controllers/ relievers, equipment return demonstration-71% (paper) Asthma Action Plan- 91% (electronic DOADI) 2012 Board Goal- 50% Asthma control medication reconciliation process-66% (paper) chronic control symptoms-67% (paper) order appropriate controllers-0% (electronic-DOADI)

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Baseline Data 1/1-12/2011

% Asthma Patients-Action Plan
100% 80%

60%
40% 20% 0%

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Teaching Meds-2011/2012 YTD

100% 90%

% of Patients Med Teaching

80%
70% 60% 50% 40% 30% 20% 10% 0%
2011.01 2011.02 2011.03 2011.04 2011.05 2011.06 2011.07 2011.08 2011.09 2011.10 2011.11 2011.12 2012.01 2012.02 2012.03

Average

% with Teaching Medications

LCL

UCL

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Solutions to Problems
Role/Responsibility delineation document created (slide 6)

Education channel, back-up DVDs in toolboxes

Staff education on the CPM (slide 7), created patient

scenarios for chronic control and step up-therapy using tools such as the Quick-Guide and Primary Care CPM DOADI revised to include new components and reduce format from 9 to 2 pages Team completed a survey to prioritize problems (slide 10) Reinforced use of the Teaching Outline Assisted units with the transition of documentation on paper forms to electronic medical records

Specific Aim Statement

From January 2011 - March of 2012, sustaining the board goals and improvement in documentation from 71%-85% (stretch) will occur with medication teaching: Sustaining the 2011 Board Goal- 81% 87% Overall Teaching of Triggers-89% 96% Medications difference between controllers/ relievers, equipment return demonstration-71% 85% (paper) Asthma Action Plan- 91% 96% (electronic DOADI) 2012 Board Goal- 50% 69% Overall Asthma control medication reconciliation process-66% 73% (paper) chronic control symptoms-67% 98% (paper) order appropriate controllers-0% 36% (electronicDOADI)

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2012 Goal -YTD

Stretch Target Yellow Red

90% (RV), 80% (System, MK, PC, UV), 75% (LG, AF, DX) 85% (RV), 75% (System, MK, PC, UV) , 70% (LG, AF, DX) Not Red, and Not Target or Stretch <80% (RV), <71% (PC), <70% (System, MK, UV), <60% (LG, AF, DX)

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2003-2011 6 Month Readmission Rate Changes

0.60 0.55 0.50 0.45 0.40

Quarterly Readmissions w/in 6 months of Discharge: PCMC

Summary

Average

0.35 0.30 0.25 0.20 0.15 0.10 0.05 0.00

Q1 2003 Q1 2004 Q1 2008 Q1 2009 Q1 2010 Q1 2011 Q1 2005 Q1 2006 Q1 2007 Q1 2012 Q2 Q3 Q4 Q2 Q3 Q4 Q2 Q3 Q4 Q2 Q3 Q4 Q2 Q3 Q4 Q2 Q3 Q4 Q2 Q3 Q4 Q2 Q3 Q4 Q2 Q3 Q4

77 67 41 55 60 45 48 53 73 60 46 77 60 49 63 80 80 62 39 75 102 83 68 62 124128113 82 127 87 72 68 119100 79 73 119

Apr 16, 2012 10:57:48

Asthma Readmission Rate Reduction at Primary Childrens and Nationally

Percentage of Inpatients who Returned Within 180 Days
40%

2010 Asthma Inpatient Encounter (APR-DRG 141) Returns to Hospital within 180 Days Same APRDRG

35%
30% 25% 20% 15% 10% 5% 0%

% Inpatient Returns

% ED Returns

Source: Child Health Corporation of Americas Pediatric Health Information System database

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Future Plans
Audit electronic

documentation
Make PCMC DVD Develop continuous

Implement web-based

self-monitoring tool and Care Process Model across the system (ED, Insta/Primary Care)
Partnerships with UDOH

albuterol protocol
Develop an asthma

and EPA (NAEPP #4) to impact triggers/home environment

Business Plan for Return

scorecard on Investment (ROI)direct and indirect measures

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Thank-you!