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Assembling Your School Asthma Team:

An Asthma Quality Improvement Collaborative

Kim Utech, MSN, FNP-C, AE-C

Develop ideas, test, and implement change

Establish measures and report data monthly

Identify a project location and set an aim

Establish a team/collaborative

Identify a problem or an opportunity for improvement

What’s the problem? The burden of asthma in New York State.

uNYS has the 2nd highest rate of asthma in the United States

u In 2015, 400,500 children had asthma

30,000 hospitalizations, 170,000 ER visits, and 287 deaths

u In 2018, there was an estimated total cost for asthma $3.6 billion

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What’s the Problem? Buffalo/ Western NY

WNY has the 2nd highest rate of asthma ER visits and the 3rd highest rate of asthma hospitalizations

u ~20% of children in Buffalo have asthma

u African-American and Latino children have the highest % of asthma

u Buffalo : high poverty rates, old housing stock, Peace Bridge, pockets of neighborhoods with high AA, and Latino children with asthma

New York State DOHAsthma Quality Improvement

Collaborative (AQIC)

§ Mission is to improve the quality of asthma care and health related outcomes among child of moderate to high-risk asthma in primary care and SBHCs settings using evidence-based practices (NHLBI/NAEPP, 2007)

§ 14 month project starting in June 2018- July 2019

§ 3 learning sessions

§ Monthly webinars and data collection

§ Rapid PDSA tests using the Model for Improvement

Act

Study Do

Plan

School Based Health Center (SBHC)P.S. 76 Herman Badillo Bilingual Academyu Provide FREE care in school to all students Enrolled in the SBHC

u Primary care services include comprehensive physicals, immunizations, diagnosis and treatment of acute and chronic medical conditions, such as asthma and obesity, and nutritional counseling

u Mental health services include assessments, counseling, crisis intervention and referrals as needed

u Safety Net to reduce gaps in care, lower emergency department and hospital rates

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u ~800 children in PreK-8th gradeu 212 children have an asthma diagnosisuOver 90% of students are enrolled in

the SBHCuMany Spanish speaking

children/families

SBHCP.S. 76 Herman Badillo Bilingual Academy

Buffalo SBHC AQIC Team

P.S. 76 School Based Health Clinic

NP, MA, SW, MD, AE-C

WNY Children’s

Environmental Health

Center (WNY CEHC)

Coordinator, Medical Director

OisheiHealthy

Kids (OHK)Care Mangers, QI

Buffalo SBHC AQIC Team

Kim Utech, FNPC, AE-C

Melinda Cameron, MD

Medical Director

Lissette Palestro, MPH

Coordinator of the WNY Children’s Environmental Health Center

Robert Mowery,

Quality, OisheiHealth Kids

Chelsea Kraska

Care ManagerSupervisor, Oishei Health Kids

Susan Boswell, FNP

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NYS AQIC AIM

- Reduce # of hospitalizations for asthma patients by 20% in the previous 6 months

- Increase the % of asthma patients classified as well controlled by 40%

- Increase symptom free days to at least 12 out of 14 days

Buffalo SBHC AQIC AIM

In 14 months, increase the number of student with asthma with EMRdocumentation of:

u AAPs by 50%u Environmental triggers by 50% u “Well Controlled” by 25%

Measures Established by NYS AQIC

u Asthma Action Plan

u Asthma Classified as “Well Controlled”

u Documented Control Classification

u Documented Severity Classification

u Documented Environmental Triggers

u Education about Environmental Control Measures

u Referrals to Home-Based Services

u Hospitalization and ED visits due to asthma

u Prescribe inhales Corticosteroids

u Documented Self – Management

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Intervention SBHC 76

Streamline Asthma Visit Process

§ Staff training: School Asthma Management (SAM) Survey Tool, NHLBI Guidelines, Asthma 101

§ Prioritized children with asthma by severity and control

§ Increase Communication§ Posters and Pictures of medications, triggers,

lungs, spacer /inhaler technique in all exam room

Intervention SBHC 76

Asthma visits were broken down into smaller multiple visits with focus on asthma education

§ SAM Survey Tool

§ AAP (medications, spacer and inhaler technique)

§ Self-management education (what is asthma, signs and symptoms, triggers, AAP)

§ Every visit: Assess smoking, spacer/inhaler technique, controller use, medication use, control

Intervention SBHC 76

Establish Linkage to Community Based Organizations:

1. OHK Health Home: for children with asthma who also have one other chronic health condition

2. WNY CEHC

3. NYS Smokers Quit line

4. Visiting Nurse Association (VNA)

5. Erie County DOH Healthy Neighborhood Program

6. Referrals to Lung Center, Allergy Clinic, PCP

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Intervention OHK and WNY CEHC:

WNY CECH: Educate OHK care managers on asthma and environmental asthma triggers

§ WNY CEHC: Environmental asthma trigger survey developed in English and Spanish (10 questions)

§ 2 Education Sessions : for 26 OHK care managers to teach them how to screen for environmental asthma triggers and review Asthma 101

§ OHK: Referral tracking system in the EMR, developed a 5 question tool

Data ResultsJune 2018 – April 2019

28

17

11 11

R E F E R R A L S R E C E I V E D R E F E R R A L S E N R O L L E D R E F E R R A L S E N R O L L E D D U R I N G A H O M E V I S I T

M E M B E R S T H A T R E C E I V E D A N O H K H O M E V I S I T

OISHEI HEALTHY KIDSVisits

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7

0

1

2

3

4

5

6

7

October February March April May

# of Children that Completed the Full Environmental Asthma Trigger Screen

Chil dren

40.00

66.67

33.33

20.00

10.00

30.00

11.11

90.00

88.89

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

90.00

100.00

June September October Novem ber Decemb er January February March April

% of Patients with an Asthma Action Plan

AAP created in P.S. 76

clinic

Documented Level of Asthma Control

20

80

60 60

20

90

80 80

100

0

10

20

30

40

50

60

70

80

90

100

Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19

Asthma Control

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Documented Level of Asthma Severity

60

50

90

70

60

80

100 100 100

0

10

20

30

40

50

60

70

80

90

100

Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19

Asthma Severity

0.00

83.33

50.00

60.00

20.00

100.00

62.50

90.00

66.67

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

90.00

100.00

June September October Novem ber Decemb er January February March April

Patients Whose Asthma is Classified as "Well-Controlled" at the Current Visit

Documented during P.S. 76

clinic visit

60.00

100.00 100.00

70.00 70.00

77.78

100.00100.00 100.00

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

90.00

100.00

June September October Novem ber Decemb er January February March April

% of Asthma Patients with an Office Visit Who Were Evaluated for Environmental Triggers

Screened by WNY CEHC

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0.00

33.3340.00

71.43 75.00

75.00

22.22

100.00100.00

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

90.00

100.00

June September October Novem ber Decemb er January February March April

% of Asthma Patients Whose Asthma is Not "Well-Controlled" Who Received a Referral to Home-Based Asthma Services

Home visits conducted by

OHK

Barriersu Staff turnover

u Time constraints

u Engagement

u No bilingual team members

u Survey return rate low

u Parents say “yes”, but can’t reach

u Fruitful visits?

Conclusions

Successes

u Established a referral system and linkage between Oishei Healthy Kids, WNY Children’s Environmental Health Center, and the SBHC which has become part of process for SBHCs

Conclusions

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u Increase referrals to EC CEHC and OHKu Introduce EC CEHC to other SBHCsu Spread referral system to other SBHCsu Sustainabilityu Asthma Coalition

Next Steps

Thank you