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For success, coach young asthma patients carefully
Individualized, creative approaches reach children
It’s not just a case of a little breathing problem. There are 6.3 million children younger than 18 with asthma.1 Asthma rates in children younger than 5 increased more the 160% between 1980 and 1994.2 In 2000, 4.6 million outpatient visits related to asthma involved children.
During the same year, more than 728,000 visits to emergency departments (EDs) for asthma-related problems and 214,000 hospitalizations involved children.3
When you look at these statistics and realize that not only is care of asthmatic children costly for the health care industry (more than $8.1 billion annually4) — parents miss work and children miss school — it makes sense to look to home health as one way to reach out to children at risk for asthma to help them learn how to avoid outpatient and ED visits.
The Visiting Nurse Service of New York (VNSNY) has provided nurses focused on asthma care for 15 years, says Maryam Navaie-Waliser, PhD, senior research associate for the Center for Home Care Policy and Research for the New York City-based agency.
"We’ve always served a large number of children, and about 30% of our clients are children with many of them being seen for asthma-related problems," she says. Of the children her agency sees, between 55% and 60% of them are younger than 5 and have been diagnosed with asthma since they were toddlers, she adds.
Because asthma is the leading referral diagnosis to the agency’s pediatric program, VNSNY conducted an evaluation of the program to make sure the care that was provided was effective for the patients and their families, says Navaie-Waliser.
"Years ago, the nurse would see an asthma patient and the family over a course of seven to 10 visits, but now we only see them three times," she explains. "This makes it critical that we make sure we are making the best use of time."
The large number of children under the age of 5, pointed out the importance of providing education that involves the parent, according to Navaie-Waliser.
"Not only do we make sure the nurse explains how to use an inhaler, when to use different medications, or what signs of an impending attack to notice, but the nurse now has the parent demonstrate the skill or knowledge by showing how to use the inhaler, or describing the signs," she continues.
With children ages 11 and older, nurses not only educate the children but involve the parents as well, explains Navaie-Waliser. "We discovered that older children benefit most when their parents can also remind them how to control their asthma, especially during an attack when the child might be anxious and forget what has been taught," she adds.
Family-specific plans most effective
Although there may be only three visits, each visit is between one and two hours long, says Navaie-Waliser. The nurse’s first visit includes a lengthy and detailed assessment that addresses the child’s health history, use of medications, timing of attacks, and environmental factors.
"During our evaluation of asthma patient charts, we realized that the quality and detail of the environmental factor assessment was key to the development of a successful asthma care plan," she says.
If asthma triggers can be identified and minimized in the home, the number of attacks will decrease, she adds.
"We design each treatment plan for the individual," says Navaie-Waliser. "One family may require education about control of roaches while another family needs to learn about the dangers of cigarette smoke around an asthmatic child," she explains.
The pediatric asthma program at Sentara Home Care Services in Chesapeake, VA, provides a longer period of follow-up, but the nurses also start out by developing an asthma treatment plan based on a thorough assessment of the patient and the environmental triggers, says Rhonda Chetney, RN, MS, director of clinical operations.
"Once the treatment plan is developed and approved by the physician, the follow-up occurs by telephone or in person as needed," she says.
Pediatric asthma patients stay in the program for one year with the greatest number of visits occurring in the first month to stabilize the child and to thoroughly assess the environment, she adds. "After the first month, most follow-ups are conducted by telephone; and the nurse will schedule a visit if there is any indication that one is needed," she explains.
Sentara’s home care nurses act as "Life Coaches" for about 600 asthmatic patients each year, explains Chetney. "Our goal is to help patients manage asthma and reduce the number of acute episodes they experience over their lifetime," she says.
Pediatric asthma patients are referred to Sentara’s program by the corporation’s health plan, says Chetney.
"High-risk children are identified through the plan by several mechanisms, including utilization of [EDs], hospitalizations, physician office visits, and prescriptions filled," she says.
When it appears that the asthmatic child is not managing the asthma, the home care agency receives the referral, she adds.
Flexibility is key to success
"The toughest part of our job is finding many of these children," Chetney says. "Most of the children are in the Medicaid HMO plan, and we often find that telephones are disconnected or no one is home during the day because of work schedules, so we’ve become creative in how we reach them," she explains.
"We’re most successful with our drive-bys where the nurse just goes to the home to see if anyone is there," says Chetney.
"If no one is home, we leave information with the reason we came and how to get in touch with us. We also make it clear that we can make the visits at night or on the weekends, whichever is best for the parent’s schedule," she says.
If it is too difficult to visit the child at home, nurses will go to after-school programs to gather information, but it is critical to get inside the home at some point to identify environmental factors that may be causing the acute episodes, says Chetney.
Another way the pediatric asthma program has partnered with the school system to help asthmatic children is the TeleCoach that has taken up residence in the school nurse’s office at one middle school where there are 200 asthmatic children. This innovative program has resulted in a 64% decrease in hospitalizations, a 33% decrease in ED visits, and a 65% drop in patient care costs for the 40 children involved.
"The monitor sits on a cart that is dressed in a warm-up suit and has a head and hat on top," says Chetney.
TeleCoach comes equipped with a stethoscope, blood pressure cuff and two-way live audiovisual capabilities using a telephone line.
The nurse who is conducting the televisit from the agency office finds out how well the children are managing their asthma, how the medications are working, and if there are any gaps in the children’s knowledge. She also answers any questions the children may have.
"We’ve had the program in place for about 1½ years, and it’s very successful," she says.
Forty children have scheduled times to meet with the "coach" every one or two weeks, usually during gym class, says Chetney.
"We offer incentive prizes for keeping their appointments," she adds. One of the reasons for success is the combination of technology that interests the children and a fun way to present information, she adds.
"Children don’t willingly go to a traditional asthma class because it’s boring, but they will come talk to the coach," Chetney explains.
Is information appropriate for your audience?
Make sure that all of your educational information, even traditional printed material, is appropriate for your audience, Navaie-Waliser suggests.
"Between 50% and 60% of our patients are Hispanic, so we have to provide bilingual care," she says.
Her agency’s educational materials are printed in English, Spanish, French, and Chinese to reflect the populations they serve, she adds.
"We also make sure the material is written at a fourth-grade level to make sure everyone can understand," she says.
Because asthma is more prevalent in an urban environment and very often in a lower income environment, it’s important to be creative and flexible when planning services for a pediatric asthma program, says Chetney.
"When you add the environmental factors to the reality that your patient may not be talking yet, you have to thing outside the box and look for nontraditional ways to reach and care for patients," she explains.
[Editor’s note: For more information about the Sentara Home Care Services’ Life Coach program, including a copy of an asthma treatment plan, see: Axelrod RC, Zimbro KS, Chetney RR, et al. A disease management program utilizing Life Coaches’ for children with asthma. Journal of Clinical Outcomes Management 2001; 8:38-42.
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