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Service Delivery Innovation Profile

Hospital-Based Asthma Educators Train Patients, Providers, and Community Members on Optimal Care, Leading to Fewer Admissions, Emergency Department Visits, and Missed Work Days


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Summary

The AH! (Asthma Health) Program uses hospital-based educators to support providers and other caregivers throughout the community (including school nurses, community health workers, pharmacists, and childcare providers) in providing quality asthma care through professional training and educational materials that support use of up-to-date action plans and proper classification and treatment of symptoms based on established guidelines. Asthma educators also meet one-on-one with patients and their families to promote better asthma self-management. The program, serving southern, central, and western Maine, significantly improved medication adherence, leading to fewer asthma-related hospitalizations, emergency department visits, and missed work and school days for parents and children.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key asthma outcomes, including medication compliance, asthma-related ED visits and hospitalizations, and workplace absenteeism, along with post-implementation patient survey results.
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Developing Organizations

MaineHealth
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Use By Other Organizations

Information about several similar county and regional initiatives that involve hospitals, schools, primary care providers, and other organizations is available at: http://www.asthmacommunitynetwork.org/programs/winners.begin ppxml

Patient Population

Adult and pediatric asthma patients with intermittent and persistent asthma in 11 Maine counties.end pp

Problem Addressed

Asthma is a common condition that is often inadequately treated, leading to many expensive hospitalizations and emergency department (ED) visits. Although self-management and community-based education can help in improving asthma care, few communities offer such programs to patients, providers, and other key stakeholders.
  • 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 the same year, 8.5 percent of children in Maine had childhood asthma,2 and the State's prevalence of adult asthma was among the highest in the country (15.7 percent—well above the national average of 13.5 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 recommends 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

What They Did

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Description of the Innovative Activity

The AH!program uses hospital-based, certified asthma educators to support providers and other caregivers throughout the community in providing quality asthma care through professional training and educational materials that support use of up-to-date action plans and proper classification and treatment of symptoms based on established guidelines. Asthma educators also meet one-on-one with patients and their families to promote better asthma self-management. Highlights of the program are detailed below:
  • 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 2012, educators conducted 46 sessions at pediatric and primary care practices, training 330 nurses, physicians, and other clinicians (updated October 2013).
    • 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 2012, the program served 164 school nurses and 110 childcare providers (updated October 2013).
    • 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 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 2012, educators met with 719 patients (some more than once), holding 583 patient education sessions (updated October 2013). 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 Back 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.

Context of the Innovation

MaineHealth is a nonprofit health care delivery system that includes hospitals and physician practices in 11 of Maine’s 16 counties. The system began working to improve asthma care because of the State's high prevalence of adult and pediatric asthma, which is caused by a variety of factors, including high smoking rates, environmental pollutants, high levels of summer ozone, densely forested regions that produce high pollen levels, and heavy reliance among Mainers on burning wood to heat homes. MaineHealth selected asthma as the first chronic illness for its clinical integration division, with the goal of improving asthma care across multiple settings.

Did It Work?

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Results

The AH! program significantly improved medication adherence, leading to fewer asthma-related hospitalizations, ED visits, and missed work and school days for parents and children.
  • 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 2012:
    • Pediatric patient improvements: In the 6-month period before 125 children met with asthma educators, 29.6 percent reported they had asthma-related ED visits. Six months after the education sessions, only 2.4 percent of the 92 who were followed during the 2012 reporting period had asthma-related ED visits. In the same group of children, asthma-related hospitalizations declined from 19 to 1.6 percent after the education sessions, and the percentage of children and parents who missed school or work declined from 35 to 10.4 percent. (Updated October 2013.)
    • Adult patient improvements: In the 6-month period before 68 patients met with asthma educators, 42 percent reported ED visits. Six months after the education sessions, only 2.6 percent of 38 adults who were followed during the 2012 reporting period had ED visits. Hospitalizations among these adults over the same time period declined from 23.7 to 0 percent, and work absenteeism during this period dropped from 63 to 42 percent. (Updated October 2013.)
  • 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?)

Moderate: The evidence consists of pre- and post-implementation comparisons of key asthma outcomes, including medication compliance, asthma-related ED visits and hospitalizations, and workplace absenteeism, along with post-implementation patient survey results.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • 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 Program 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.
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Funding Sources

MaineHealth
Asthma educators at participating hospitals receive a grant to support the educator’s salary. The expectation is that the financial support will be reduced each year as the hospital-based education program works toward self-sustainability. Medicare, Medicaid, and most private insurers in Maine reimburse a portion of the cost of asthma education, which generally runs about $120 for an hour-long session.end fs

Tools and Other Resources

National Asthma Education and Prevention Program, National Heart, Lung, and Blood Institute, Expert panel report 3 (EPR3): guidelines for the diagnosis and management of asthma. Available at: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.

National Heart, Lung, and Blood Institute. Asthma Action Plan template. Available at: http://www.nhlbi.nih.gov/health/public/lung/asthma/asthma_actplan.htm.

AH! Asthma Health: Asthma treatment clinical guidelines for primary care providers. Available at: http://www.mainehealth.org/mh_body.cfm?id=363.

AH! Asthma Health: Patient education materials: Available at: http://www.mmc.org/mh_body.cfm?id=263.

Adoption Considerations

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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.

Use By Other Organizations

Information about several similar county and regional initiatives that involve hospitals, schools, primary care providers, and other organizations is available at: http://www.asthmacommunitynetwork.org/programs/winners.

More Information

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Contact the Innovator

Kathleen Beers, RN, BSN, CDE
Program Manager, Chronic Disease
MaineHealth - Clinical Integration
110 Free Street
Portland, ME 04101
(207) 662-0766
E-mail: beersk2@mmc.org

Innovator Disclosures

Ms. Beers has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

Roderick PS, Osgood JL, Letourneau L, et al. The AH! asthma health clinical practice collaborative: a model to improve asthma care. J Allergy Clin Immunol. 2004;113(2 Suppl 1):S319. Available at: http://download.journals.elsevierhealth.com/pdfs/journals/0091-6749/PIIS0091674904006918.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).

Footnotes

1 National Heart, Lung, and Blood Institute. Morbidity & mortality: 2009 chart book on cardiovascular, lung, and blood diseases. Bethesda, MD: National Institutes of Health, 2009. Available at: http://www.nhlbi.nih.gov/resources/docs/2009_ChartBook.pdf.
2 Centers for Disease Control and Prevention. 2010 child asthma data: prevalence tables. Available at: http://www.cdc.gov/asthma/brfss/2010/child/current/tableC1.htm.
3 Centers for Disease Control and Prevention. 2010 adult asthma data: prevalence tables and maps. Available at: http://www.cdc.gov/asthma/brfss/2010/lifetime/tableL1.htm.
4 Wolfenden L, Diette G, Krishnan J, et al. Lower physician estimate of underlying asthma severity leads to undertreatment. Arch Intern Med. 2003;163(2):231-6. [PubMed] Available at: http://archinte.jamanetwork.com/article.aspx?articleid=215003.
5 National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007. J Allergy Clin Immunol. 2007;120(5 Suppl):S94-138. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: May 11, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: November 20, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: September 25, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

Back Story
When an asthma patient is treated at Maine Medical Center’s emergency department (ED), the treating physician clicks a box in the patient’s electronic medical record, automatically sending an order for asthma education to the hospital’s asthma educator, Rhonda J. Vosmus. Vosmus, a respiratory therapist and one of 2,500 nationally certified...

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