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Asthma Action Plans for Your Patients and Communities Gerri L. Mattson, MD, MSPH, FAAP Pediatric Medical Consultant Children and Youth Branch
Asthma Action Plans for Your
Patients and Communities
Gerri L. Mattson, MD, MSPH, FAAP
Pediatric Medical Consultant
Children and Youth Branch
Cole Thomas
Cole is 4 years old and new to your clinic. Mom has completed all of the forms for you and you have them on the front of the chart
to review before you walk in the room.
Cole Thomas
8 8
Ann Thomas 4/19/13
2 mos pregnant
2 mos
Paul Thomas, dad, 25Ann Thomas, mom 24
no
dad
Dad
4/17/09
Mother
v MGM
MGM
What did you learn from the
Initial History Questionnaire?
x
x
xx
x
x
wheezing
x
xxx
xx
x
x
x
x
x
xx
x x
xx
What did you learn from the Pre-
Visit Questionnaire?
Wheezing problems, cough X 1 week, no fever, eating less well, but drinking and voiding well, dad has cold
none none
mom
34 lbs (40%)
English 4/19/13 Cole Thomas
581967
40in (40%) 15 (40%) 90/52 98.7 4/17/2009 4 years
xx x
ER 3 times in last 6 months for wheezingHospitalized 2x in last 2 years for wheezing (no ICU admits)
x
xx
Has been on albuterol inhaler but ran out last month
child care in friend’s homex
x
xMoved to area about 3 weeks agofrom Maryland
PEDS: Pass
x
x
x
x xx
x
xxx x
xx
xxx
xxxx
lungs: diffuse expiratory wheezes posteriorly, decreased breath sounds at bases, no retractions, mild increased WOB
Alert, smiling, interactive, RR 28no stridor, no audible wheezes
new patient
Skips breakfastx
x Up at night coughing, restless
xx
xx
x
1) Asthma exacerbation 5) Increased screen time
x
Bright Futures and asthmaxx x
DTaP, IPV, MMR, Varicella
developmental screening results discussed with parents x x
2) Asthma –moderate persistent 3) URI4) Second hand smoke exposure
Gerri L. Mattson, MD Gerri L. Mattson, MD
x
4/2014 well visitRecheck asthma in 1 week
x
CC4C
x
4/19/13 NN 4/19/13 NNx x
xx
20/2020/20
Pass Pass PassPass Pass Pass
581967Cole Thomas4/17/09
Plan:
1) Asthma exacerbation-Gave albuterol 2.5 mg nebulized treatment in clinic-After completed neb, listened after 10 min and increased aeration and decreased wheezes-Gave Rx for Proventil HFA MDI to use with spacer 2 puffs every 4-6 hours for 7 days then prn-Instructed on use of spacer with demonstration MDI and parent and child demonstrated good use of MDI with spacer-Gave two spacers (one for home and one for child care)-Gave Rx for prelone (15mg/5ml) 30 mg once a day for 5 days Disp: 50ml-Return appt in 7 days to recheck-Return to clinic sooner if wheezing worsens or increased work of breathing or need Proventil more than every 4-6 hours, decreased oral intake or urine output
2) Asthma – moderate persistent-Used asthma assessment questionnaire – though not on meds at time-Asthma action plan completed and reviewed (identified and reviewed triggers)-Medication form completed for preschool-Instruction on use of MDI with spacer and meds as above for next week-Start flovent 44 mcg 2 puffs bid with spacer (rinse mouth out with use)-Refer to CC4C-Assess asthma control in follow up in 4 weeks when not having acute exacerbation
3) URI-Trigger for asthma exacerbation this time-Will not use any OTC meds or decongestants-Return to clinic if fever > 101.5 for more than 2 days or if cough worsens
4) Second hand smoke exposure-Gave mom information to share with dad about importance of quitting smoking because worsensasthma and NC Quit Line
5) Increased screen time-Provided anticipatory guidance to mom about appropriate limits and impact
Gerri L. Mattson, MD
4/24/2013 9:21:47 AM DRAFT
Cole Thomas
Dr. Mattson
4/17/2009
4/19/2013
Flovent 44mcg 2 puffs twice a day x
x
xProventil HFA
x
x
x
x
Proventil HFA5-7
Proventil HFA
x
x
x
Gerri L. Mattson, MD 4/19/13 919-250-4570
Wake Child Health Clinic
x
x
x
CC4C Role
• Monitoring asthma CHIPRA and CCNC measures for children birth to five years of age
• Help with education about messages from medical home and use of asthma action plan
• Potential to help parents and child care providers understand and use asthma action plans and to help monitor for control of asthma
4/24/2013 9:21:47 AM DRAFT
Themes of the Six National Asthma Education
and Prevention Program (NAEPP)/NHLBI
Messages From Latest Expert Panel Report
• Initial severity assessment (includes impairment and risk)
• Asthma action plan is needed
• Inhaled corticosteroids are best for long-term management
• Asthma control assessment at follow up visits
• Follow up visits needed to assess control and modify treatment
• Exposure to allergens and irritants (triggers) should be reviewed and reduced
4/24/2013 9:21:47 AM DRAFT
CMS 20/QMAF Annual number of asthma patients (>1 year old) with >1 asthma related ER visit x N3CN
QMAF Continued care visit (Annual Chart Audit) x x N3CN-Chart
QMAF Asthma Action Plan (Annual Chart Audit) x N3CN-Chart
QMAF Environmental triggers (Annual Chart Audit) x N3CN-Chart
QMAF Appropriate pharmacological Rx (Annual Chart Audit) x N3CN-Chart
QMAF Beta-agonist overuse (Claims Data - Quarterly) x N3CN
QMAF Absence of controller Rx (Claims Data -Quarterly) x x N3CN
QMAF Asthma hospitalizations (Claims Data-Quarterly) x N3CN
TYPE Pediatric Quality Measure Name (based on national guidelines)CCNC Annual
reporting
CCNC Quarterly-
Useful for QI PEHR Measures for use in
CHIPRA Category D Data Source
Key:
N3CN = North Carolina Community Care Network
CMS = Centers for Medicaid and Medicare (Federal)
QMAF = Quality Measurement and Feedback Initiative (CCNC)
QI = Quality Improvement
PEHR = Pediatric Electronic Health Record
Asthma CHIPRA and CCNC Efforts With LHDs
Enrolled in Carolina Access II Networks
4/24/2013 9:21:47 AM DRAFT
*
*
*Big focus on ER visits
and hospitalization as
well as other measures
Initial Assessment
• All patients should have an initial severity assessment (objective and subjective) that covers impairment (Evidence B) and future risk (Evidence C&D)– Classifying asthma severity and initiating treatment for children
0-4yrs, 5-11yrs and 12yrs and older
– Assessment includes:
• Symptoms: nocturnal awakenings, need for quick relief to control symptoms, school/work absence, quality of life and interference with daily activities
• Lung function (spirometry is used to confirm a diagnosis of asthma based on obstruction and reversibility) = not done if less than 5 years typically
• Risk is determined by the number of asthma exacerbations that need for oral steroids and accounts for severity of exacerbation and interval since last one
Borrowed and adapted from a slide by Dr. Cloutier,
Connecticutt Children’s Medical Center NCE, October 20124/24/2013 9:21:47 AMDRAFT
Impairment
Example of Cole Thomas’ Asthma Health Assessment Tool
Available in English and Spanish
4/24/2013 9:21:47 AM DRAFT
3
3
1
None now but was using every day
4/24/2013 9:21:47 AM DRAFT
NHLBI: Classifying Asthma Severity: Intermittent, Mild Persistent, Moderate
Persistent or Severe Persistent 0-4 and 5-11 years of age
http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf
Asthma Action Plan Message
All people with asthma should receive a
written asthma action plan (Evidence B)
– May help patients with understanding and
improve asthma control
– Improves self-efficacy and management
– Educates on signs and symptoms early vs. late
– Increase awareness of asthma triggers to identify,
avoid and eliminate
Adapted from Dr. Cloutier, Connecticutt Children’s Medical
Center NCE, October 20124/24/2013 9:21:47 AM DRAFT
4/24/2013 9:21:47 AM DRAFT
http://www.asthma.ncdhh
s.gov/docs/AsthmaActionP
lanRecommendedSchoolAs
thmaActionPlan(2)-1.pdf
Cole Thomas
Dr. Mattson
Coaches Clipboard Program
• Tools for educating coaches, PE teachers, and other rec personnel who work with children with asthma in schools
• Includes an interactive educational tool and a clipboard outlining procedures for working with children with asthma and understanding asthma action plans
• Local asthma coalitions in Harnett, Cleveland and Davidson are using this program
Message on Inhaled Corticosteroids
Inhaled corticosteroids are the most effective
anti-inflammatory medications for long-term
management of persistent asthma
(Evidence A)
Borrowed from Dr. Cloutier, Connecticutt Children’s Medical
Center NCE, October 20124/24/2013 9:21:47 AM DRAFT
Asthma Comparative Effectiveness (ACE) Research
Shared Decision Making Toolkit
https://www.dicksoninstitute.com/FamilyMedsTools/SharedDecisionMakingToolkit.asp4/24/2013 9:21:47 AM DRAFT
Asthma Control Message
Asthma control should be assessed at every
follow-up visit (Evidence A&B)
4/24/2013 9:21:47 AMDRAFT
ACT* for Younger Children
*Available in English and Spanish
4/24/2013 9:21:47 AM DRAFT
http://www.asthma.com/resource
s/asthma-control-test.html
NAEPP/NHLBI Message on Periodic
Follow Up Visits
Patients with asthma should have periodic
follow up visits to assess asthma control and
modify treatment as needed (Evidence B)
4/24/2013 9:21:47 AM DRAFT
Frequency of Asthma Visits
• Intermittent Yearly*
• Mild, persistent 2 times/yr
• Moderate, persistent 3-4 times/year
• Severe, persistent 6-12 times/yr**
– * Can do during yearly physical
– ** Follow jointly with specialist
Borrowed from Dr. Cloutier, Connecticutt Children’s Medical
Center NCE, October 20124/24/2013 9:21:47 AM DRAFT
4/24/2013 9:21:47 AM DRAFT
NHLBI: Assessing Control and Adjusting Therapy
http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf
4/24/2013 9:21:47 AM DRAFT
NHLBI: Stepwise Approach for Managing Asthma Long Term
http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.pdf
Message on Exposure to Asthma
Triggers
Exposure to allergens and irritants should be
reviewed and a multi-pronged strategy to
reduce those allergens should be provided
(Evidence A&C)
Borrowed from Dr. Cloutier, Connecticutt Children’s Medical
Center NCE, October 2012
4/24/2013 9:21:47 AM DRAFT
Self Management: Knowing
Asthma Triggers
“Identify” to “Avoid” and try to “Eliminate”
A “trigger” is an object, act, or event that causes the airways to become more sensitive/inflamed and leads to asthma symptoms.
Patients/parents should know what their child’s triggers are and try to avoid or eliminate those things.
4/30/2012 v2Borrowed from CCNC training
DRAFT29
Non-Allergic Triggers: For All Children
with Asthma
• Second hand and third hand smoke from cigarettes and other forms of tobacco or drugs
• Smoke inhalation from fireworks, outdoor burning, campfires or indoor log fires
• Airway infections
• Strong odors and fumes
• Kerosene heaters
• Changes in weather especially cold air
• *Exercise for some but regular physical activity is important and the goal is to control asthma to allow for exercise
4/24/2013 9:21:47 AMDRAFT
Allergic Triggers: For Some Children
with Asthma
• Dust mites
• Cockroaches
• Animal allergens
• Molds
• Pollen
4/24/2013 9:21:47 AM DRAFT
Working with Your Communities
• Air Quality Flag Program
• Anti-idling Messaging
• Home environmental assessments for asthma
patients: examples of current programs in
partnership with LHDs in Alamance, Wake,
Johnston, and Davidson counties
NC Asthma Program
The North Carolina Asthma Program strives to reduce the burden of asthma upon the citizens of our state by:
• Developing and maintaining a comprehensive statewide asthma surveillance system.
• Developing and implementing a State Asthma Plan that effectively addresses asthma in all ages, ethnic groups, backgrounds, and in multiple settings.
• Increasing public awareness of the importance of reducing the burden of asthma and the need for supportive policies and environments.
• Providing technical assistance and resources to help support local asthma coalitions.
• Providing leadership and administration for the statewide asthma coalition, the Asthma Alliance of North Carolina (AANC).
http://www.asthma.ncdhhs.gov/index.htm
4/24/2013 9:21:47 AM DRAFT
Getting Started on Your County’s Local
Asthma Coalition• Staffing
• Members
• Funding
• Community Champions
• A Resource: From the Ground Up by AHEC and Community Partners (coalition building and community development work book available from the NC Asthma Program) NC Asthma Program can make available coalition trainings
• Contact the Asthma Program Staff at 919.707.5213
or at http://www.asthma.ncdhhs.gov/
4/24/2013 9:21:47 AM DRAFT
