Problem Addressed

• A common, costly condition (especially in Maine): Asthma is a chronic inflammatory disease of the airways affecting more than 23 million Americans.¹ Asthma causes nearly 500,000 hospitalizations each year,¹ while asthma treatment cost $15.6 billion in 2010.¹ In 2007, 9 percent of children in Maine had childhood asthma² and the state's incidence of adult asthma was the highest in the country (9.7 percent, well above the national average of 8.5 percent).³
• Inadequate diagnosis and treatment: According to studies, some health care providers underestimate the severity of asthma in patients and consequently fail to treat its symptoms, increasing the risk of costly hospitalizations and ED visits. Physicians often need to be educated about appropriate diagnosis, monitoring, and treatment and made aware of recommended clinical treatment guidelines.⁴
• Lack of self-management education: Because asthma patients are at risk for recurrence even if they have intermittent symptoms, national guidelines recommend that providers teach patients to self-monitor and manage the disease through a written action plan. However, busy primary care providers often lack the time or staff to provide indepth patient education, and many patients either lack up-to-date action plans or do not understand how to implement them.⁵
• Lack of comprehensive community education: The National Asthma Education and Prevention Program's Guidelines for the Diagnosis and Management of Asthma recommend community-wide education to promote patient self-management skills and control environmental factors that exacerbate asthma symptoms. Although providers, pharmacists, school nurses, community health workers, and childcare providers could benefit from such asthma education, few organizations provide it across multiple settings within a community.⁵

Description of the Innovative Activity

• Hospital-based educators: Full- or part-time nationally certified asthma educators (respiratory therapists or nurses) work out of hospitals in the MaineHealth system to provide asthma education and training to providers, patients, and other community members.
• Multipronged community-wide professional education: The program has developed the following education and outreach programs for different types of providers:
  • Hospital-based providers: The program disseminates summaries and verbatim copies of the most recent National Heart, Lung, and Blood Institute (NHLBI) clinical guidelines for ED and inpatient care of asthma. Educators also conduct internal training to update hospital staff about new medications or guideline changes, and participate in grand rounds to enhance staff training.
  • Primary care providers: Asthma educators meet with primary care practice teams to provide updates about clinical guidelines and new medications, and to help providers understand how to classify asthma severity and determine an appropriate level of control. Educators provide a variety of tools to these practices, including an Asthma Clinical Guidelines Flipchart, patient questionnaires to help determine the severity of symptoms, triage questions to use when patients present with asthma as a chief complaint, new asthma encounter forms, patient flow models for caring for patients with asthma, followup encounter forms, and a template to facilitate chart review, coding, and billing. In fiscal year 2008, educators conducted 39 sessions at pediatric and primary care practices, training 325 nurses, physicians, and other clinicians.
  • School nurses: Educators work with school nurses to support the use of asthma action management and school plans. Educators also make presentations at school nurse conferences to provide updates about new medications and changes in clinical guidelines related to children and teens.
  • Childcare providers: Asthma educators meet with staff at childcare facilities and preschools to inform, educate, and prepare them to care for children with asthma. They also attend childcare conferences to share updates in asthma care. In fiscal year 2008, the program served 502 school nurses and childcare providers at 26 facilities.
  • Pharmacists: The program's Web site offers pharmacists a form they can use to alert providers if they are refilling one of their patient's quick-relief medications frequently, or if a patient has not refilled a prescription for a controller medication. The goal is to inform physicians on a timely basis about changes in a patient's condition and/or medication needs.
  • Community health outreach workers: Asthma educators train Community Health Outreach Workers in Portland, ME, who serve at-risk and underserved populations, including homeless individuals and Latino and Somali immigrants. The educators teach the workers about asthma and provide educational materials that have been translated into appropriate languages. The program also established a telephone-based asthma helpline for Somali and Latino communities to serve as a bridge between minority communities and the health care system.
• Patient education: Asthma educators meet one-on-one with patients and family members to provide self-management education. In fiscal year 2008, educators met with 424 patients (some more than once), holding 598 patient education sessions. Key elements of the patient education program are outlined below:
  • Referrals: Patients are primarily referred by outpatient providers and also by hospital staff during an inpatient admission. Some hospitals' electronic medical record systems automatically refer patients to the educator when asthma medications are dispensed by the ED. Patients can also be referred by asthma specialists, school nurses, and childcare providers.
  • One-on-one patient education: The asthma educator meets with a patient (and often family members) at the hospital for roughly 1 hour, reviewing the patient’s asthma history and recent hospitalizations or ED visits and exploring which factors trigger asthma exacerbations. The asthma educator assembles information about the patient’s weight, tobacco use, past office visits, and the severity of asthma based on provider reports, medication history, asthma control test results, and the asthma action management plan. The educator teaches patients how to track symptoms and take medications appropriately and reviews the asthma action plan with the patient. Six months after the initial session, the educator calls the patient to check on his or her status and see if additional education could be useful. (For more information on these sessions, please see the Story associated with this profile.)
  • Ensuring access to medications: Educators find that approximately 9 percent of patients cannot afford an inhaler and medications (which cost up to $300 a month) because they are uninsured or have a high deductible. In these instances, the educator refers the patient to a free clinic, government health insurance program, or local programs such as CarePartners (see http://www.innovations.ahrq.gov/content.aspx?id=1689) that can help them obtain free or low-cost drug treatment.

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Innovator Disclosures

Results

• Fewer hospitalizations and ED visits: Asthma-related hospitalizations and ED visits declined markedly in the 6 months following patient education sessions at one MaineHealth member hospital, Maine Medical Center in Portland, during 2008:
  • Pediatric patient improvements: In the 6-month period before 193 children met with asthma educators, 22.2 percent reported they had asthma-related ED visits. Six months after the education sessions, only 4.7 percent of the 85 who were followed during the 2008 reporting period had asthma-related ED visits. In the same group of children, asthma-related hospitalizations declined from 23.8 to 0 percent after the education sessions, and the percentage of children and parents who missed school or work declined from 49.4 to 7.8 percent.
  • Adult patient improvements: In the 6-month period before 59 patients met with asthma educators, 41 percent reported ED visits. Six months after the education sessions, only 5.5 percent of 18 adults who were followed during the 2008 reporting period had ED visits. Hospitalizations among these adults over the same time period declined from 6.8 to 0 percent, and work absenteeism during this period dropped from 31 to 0 percent.
• High patient satisfaction: A survey completed by 27 program participants showed 85 percent found the educational sessions to be very helpful, 96 percent reported feeling more confident about self-treatment, and 100 percent would recommend the program to others with asthma.
• Better medication compliance: Surveys of those served by patient educators during a Community Collaborative in 2005 show that adherence to appropriate use of controller medications improved from 0 to 94 percent in a homeless population, and from 7 to 100 percent among patients treated at an outpatient family practice center during a Clinical Practice Collaborative in 2002.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Crafting collaborations to reduce chronic disease: MaineHealth launched its Clinical Integration Division to improve chronic care management across medical and community settings after several years of planning by its governing boards.
• Forming steering committee: MaineHealth formed an asthma steering committee, made up of physicians, administrators, nurses, and quality improvement and information services specialists. This committee developed clinical process plans, identified integration initiatives and potential partners, and oversaw implementation efforts.
• Identifying goals and program components: Program leaders decided to replicate asthma care goals and initiatives that had been identified by the National Asthma Education and Prevention Task Force of NHLBI, including increasing public awareness of asthma, improving asthma-related practices among a diverse group of health care providers, integrating asthma education throughout the communities served by MaineHealth, and supporting public policies to improve asthma care and air quality in Maine.
• Reaching patients and providers through partnerships: The Maine Medical Center Physician Hospital Organization became an integral partner in promoting the program, disseminating information about it to affiliated physician practices. Program leaders also launched public education campaigns, including an asthma curriculum for childcare providers, and developed collaborations with businesses, schools, and public health organizations, especially those catering to minority and underserved populations.
• Shifting funding to hospitals and payers: After the initial grant funding for the pilot program, a portion of the funding for asthma educator salaries shifted from MaineHealth to the individual hospitals where educators are based. As referrals increased, these salaries have increasingly been supported by third-party insurance reimbursement.

Resources Used and Skills Needed

• Staffing: Depending on the size of the community and number of referring sources, a hospital may have one or more full- or part-time, nationally certified asthma educators, typically a nurse or respiratory therapist. Each hospital-based asthma educator may receive some administrative support. At Maine Medical Center, for example, one full-time equivalent asthma educator works with pediatric and adult patients as well as those served on an outpatient basis. A part-time educator currently works with patients in the pediatric clinic. In addition, the program's medical director typically dedicates several hours per week to the program. At the program level, MaineHealth employs one full-time health educator as program manager, with part-time administrative support and medical supervision. The manager is responsible for working with educators, the physician hospital organization, managing day-to-day operations, and producing educational materials for providers and patients.
• Costs: Nonsalary costs for materials, publications, marketing, travel, and consulting services run $120,000 a year.

Funding Sources

Tools and Other Resources

Getting Started with This Innovation

• Identify potential champions: Identify potential program champions at a hospital or health care delivery system who are committed to improving asthma care across a community. Potential champions include respiratory specialists, nurse educators, physicians, and others who can effectively promote asthma education across organizations.
• Emphasize cost-saving potential: To help secure funding, research and share data on the current cost of poorly treated asthma in the community, including preventable hospitalizations and ED visits. Identify and share data on adherence with recommended clinical treatment guidelines, highlighting the potential for improvement.
• Invite potential partners to develop program: To ensure buy-in and the building of strong relationships, ask potential partners to join the startup committee. If the plan calls for work on public policy issues affecting asthma—such as working for improved air quality—invite policymakers to participate as well.
• Promote the program to generate referrals: Dedicate staff time to visiting local primary care practices and other community organizations to familiarize potential referral sources with the education service. Partner with statewide initiatives and other community organizations to generate awareness of the program.
• Widely distribute customized educational materials: Produce educational materials (both online and printed) designed to help stakeholders promote better asthma treatment in the community. Customize patient materials for specific patient populations.
• Expect little if any third-party reimbursement initially: Until providers become familiar with the program and begin making referrals, insurance reimbursement for education services will likely cover less than one-third of costs. As a result, the program will require startup funding from the sponsoring organization.

Sustaining This Innovation

• Encourage providers to refer all asthma patients: Patients may not participate in the program if they feel they are being referred only because they sought treatment in an ED or believe they are being singled out for some inadequacy in medication compliance. To avoid this problem, providers need to assure patients that everyone with asthma is referred to the program.
• Train primary care providers and hospital staff: Programs that lack adequate resources to offer free educational sessions to the uninsured should consider training hospital, ED, and primary care staff to provide brief educational sessions to patients when they come in for treatment.
• Train educators on resources for free or low-cost drugs: Educators must be aware of potential sources of insurance coverage and/or low-cost or free drugs for those who cannot afford medications.

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