Critical Path Network

Education decreases ED visits for young asthma patients

Team works with patients and families

A pediatric asthma program that includes home visits by an asthma management team and an intensive educational program for families has resulted in a dramatic drop in emergency department (ED) visits for pediatric asthma patients at Hurley Medical Center in Flint, MI.

"Pediatric asthma is the No. 1 reason that children are admitted to the hospital throughout the country; but in our county, it has become the No. 3 reason for juvenile hospitalizations since we began our pediatric asthma case management program," says Jan Roberts, RNC-AEC, pediatric asthma disease manager.

The pediatric asthma case management team consists of Roberts and another nurse and a social worker. Roberts is a certified asthma educator.

The team works with the young patients and their families to help them better understand the disease and how to control it, including educating them on appropriate use of medications, improved compliance with treatment plans, and better control of environmental triggers.

Assessing patients and following up

Home assessments and follow-up visits in the home are a key to the success of the program, Roberts says.

The team has found that making home visits was more effective than just sending out literature and conducting disease management by telephone.

"The improvement increases with the level of intervention. If the families receive just a phone call and a packet of educational material, it makes a difference, but not as much difference as when they receive home visits," Roberts says.

Whenever possible, the case management team visits the home of every patient in the program. The team conducts a home assessment, going through the home from top to bottom and identifying asthma triggers.

If the family is uncomfortable with the assessment, the team may postpone it until a subsequent visit or may look just in the child’s room.

Initially, all members of the team visit the home. Follow-up may be by only one team member.

The goal is to help the families learn about asthma and make sure they have no barriers to optimal treatment, resulting in a decrease in ED visits, hospitalizations, and school absences.

"At the home, we determine what their needs are, whether they need help with insurance, if they know what medications to take and when, and if they have an asthma action plan," Roberts explains.

The interventions are physician-driven and patient-driven, depending on what the patient needs.

"Some need just two home visits with a lot of education. Others need a monthly phone call and some may need a monthly or bimonthly visit," she adds.

If the case management team is having trouble getting a child’s asthma under control, it has a team meeting with the physician and other clinicians, the parents, and anyone else who might have input into what can be done for the child.

In many cases, the patients are not using their medication properly. They get their daily medication and their rescue medication confused.

Home visits may be as short as 15 minutes or as long as 1½ hours.

"The visit can overwhelm the clients, and we break it up into segments," she says.

Patients and their families respond well to home visits because they are on their own turf and feel more comfortable than in a professional setting, Roberts says.

Visiting the home gives the case managers an opportunity to structure their teaching around what kind of asthma triggers may be in the home and allows them to see if there are other issues with which the family needs help.

"We make sure the family’s basic needs are being met. People won’t worry about asthma if they don’t have any food. We help them get food or help with their utilities and then worry about asthma," she says.

In the case of teenage patients, who often are reluctant to use their medication, the team comes up with a contract, asking them to try to follow the treatment plan for a month so they will see the difference it makes.

"If they try it for a month, they usually buy into the program because they feel a lot better," Roberts says.

The team goes to local schools and instructs teachers in the classroom on how to respond early on.

"If the teacher knows what to do when a child seems to be getting into trouble, she can help the child avoid a visit to the emergency department," she says.

Many of the young asthma patients who come into the ED have no insurance coverage. The case managers work with the family to get insurance through state-funded programs. In some cases, a state-funded program will pay for a one-time diagnostic visit and will cover only asthma treatment.

They tap into community resources that provide coverage for medication and primary care physicians.

"Some children with insurance need it because their families may not have the money to cover copays or prescriptions," she says.

Many of the families are qualified for Medicaid and don’t realize it. The asthma management team works to get them qualified.

"We want to eliminate all barriers to getting the medication they need," Roberts says.

If there are no other options, the asthma clinic supplies the patients with asthma medication samples.

Most of the patients are referred by their physicians. The program also takes referrals from any patient younger than 18 who has been in the ED for asthma.