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Asthma management programs have dramatically reduced emergency department (ED) visits and hospital admissions at two health care systems: Kaiser Permanente Medical Group in Rancho Cordova, CA, and Henry Ford Health System in Detroit.
Henry Ford reduced ED admissions by 50% at its pilot site, which implemented the program in the winter of 1994. Kaiser estimates a $30,000 savings in hospitalizations since the program began in April 1997. Although both programs are successful, each program has a different approach to patient education. Patient Education Management highlights the key elements of each program:
• A systematic program referral.
When a person comes to the ED at Kaiser because his or her asthma is out of control, a charge nurse at the Northern California HMO sends the patient’s name and membership number to the educator in the asthma program, explains Jimmie Lucas, RN, charge nurse for allergy and immunology at Kaiser Permanente Medical Group, so she can contact them and set up an appointment. Also, patients treated for asthma by their primary care physician are referred to the program.
At Henry Ford Health System, newly diagnosed asthmatics are sent to the program by their primary care physician, says Roberta Eis, RN, BSN, MBA, project manager for the health system. Other patients who might benefit from the program are identified by reviewing data collected over a two-year period by the hospital to determine which patients have visited the ED for asthma treatment or been admitted to the hospital.
• Individual vs. group teaching.
Adults who agree to participate in the asthma management program at Henry Ford are enrolled in a three-hour group class. The class is limited to 10 asthma patients and their family members.
To provide individual attention in a group setting, participants follow an interactive workbook called Peak Performance that was designed specifically for the class. Plans are being made to sell the workbook in the future. In addition to the workbook, presentations and a video are used to teach the curriculum, which includes pathology, triggers, use of peak flow meters, and medications. (For more information on the educational materials used in the Henry Ford Health System asthma management program, see story, p. 134.)
In their workbook, patients check off what triggers their asthma and fill out a Contract to Breathe. The contract identifies a patient’s support system and the lifestyle changes they will make.
"The program tries to engage patients rather than throw a lot of material at them," says Eis.
Pediatric patients ages 5 through 17 and their parents are given one-on-one instruction by a registered nurse. In this way, the lessons can be tailored to the age of the individual. (For more information on Henry Ford’s pediatric program, see article in Focus on Pediatrics.)
At Kaiser, patients in the Comprehensive Asthma Management Program (CAMP) book a 21¼2 hour appointment for education and a physical exam by a physician who creates an action plan for use of medications. All teaching is individualized. The nurse educator discusses ways the patient can avoid asthma triggers, after he or she has had a skin test to help determine allergies. Also, a pharmacist works with patients to make sure they are using their metered-dose inhalers correctly and that they understand when to take other prescribed medications. (For a detailed description of the initial education session at Kaiser, see story, p. 134.)
• Keeping patients on track.
Following the multidisciplinary educational session, Lucas calls the patient within 48 hours to review the information. The patients return for a follow-up visit within two to three weeks following the first appointment so the physician can adjust medications. After that, visits are scheduled on an as-needed basis.
Patients are encouraged to contact the CAMP team when they have a problem and are given an emergency number they can call 24 hours a day, seven days a week.
"We want to get everyone to a level where they can either manage their asthma or access us," says Lucas.
At Henry Ford, patients are asked if it is all right to contact them following the class. A nurse phones patients who agree to be contacted within two to three months of the class. The conversation includes questions about whether the patient is keeping a peak flow diary, if he or she is able to keep a normal routine or has missed work because of asthma, and if the workbook has been a useful reference, explains Eis.
• Creating a safety net.
Patients can fall through the cracks. While most patients willingly enroll in the asthma management class, many don’t show up. On average, about 50% of those who sign up for class actually attend, says Eis. Therefore, staff have begun to contact patients who do not attend to see if they can enroll them in the next class.
Also, the health system is engaging the aid of their home health department to reach those people who cannot come to a clinic to attend a class.
"The home health department will take the program to the patient’s home showing the videos and going over the educational materials," says Eis.