Core measures collected across 8 clinical sites for the New England Asthma Innovations Collaborative, an asthma home visiting program with education and environmental trigger remediation components Permission required for use and distribution. Please contact Christine Gordon at [email protected] for more details.
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1 New England Asthma Innovation Collaborative Enrollment & Exclusion Criteria and Core Measures – 12/6/12 Final Copy Participants Participants will be enrolled in the intervention according to the enrollment and exclusion criteria below. Enrollment Criteria • Aged 2 – 17 years old • Medicaid or CHIP beneficiary or WIC (185% FPL) or free (130% FPL) or reduced school lunch (185% FPL) recipient (Note: The majority of participants should be Medicaid/CHIP recipients. No more than 30% of the total NEAIC participants can be non-Medicaid/CHIP.) • A diagnosis of asthma from an authorized clinician • Poorly controlled asthma as evidenced by at least one of the following in the 12 month period prior to enrollment : o Asthma-related ER visit, o Observation stay, o Hospitalization, o Prescription for oral corticosteroids Exclusion Criteria • The child has other medical conditions that affect the child’s breathing (e.g. poorly controlled sickle cell disease or cystic fibrosis) • The child is already a participant an asthma intervention that will interfere with the CHW intervention • The child is homeless (if this will interfere with the administration of the environmental components of the intervention, such as living in a motel or homeless shelter) • The child is in state custody (if this will interfere with the administration of the environmental components of the intervention)
Transcript
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New England Asthma Innovation Collaborative Enrollment & Exclusion Criteria and Core Measures – 12/6/12 Final Copy Participants Participants will be enrolled in the intervention according to the enrollment and exclusion criteria below. Enrollment Criteria
• Aged 2 – 17 years old • Medicaid or CHIP beneficiary or WIC (185% FPL) or free (130% FPL) or reduced
school lunch (185% FPL) recipient (Note: The majority of participants should be Medicaid/CHIP recipients. No more than 30% of the total NEAIC participants can be non-Medicaid/CHIP.)
• A diagnosis of asthma from an authorized clinician • Poorly controlled asthma as evidenced by at least one of the following in the 12 month
period prior to enrollment: o Asthma-related ER visit, o Observation stay, o Hospitalization, o Prescription for oral corticosteroids
Exclusion Criteria
• The child has other medical conditions that affect the child’s breathing (e.g. poorly controlled sickle cell disease or cystic fibrosis)
• The child is already a participant an asthma intervention that will interfere with the CHW intervention
• The child is homeless (if this will interfere with the administration of the environmental components of the intervention, such as living in a motel or homeless shelter)
• The child is in state custody (if this will interfere with the administration of the environmental components of the intervention)
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Baseline – Pre-Intervention Caregiver Questions What is your relationship to this child?_____________________ What is your child’s gender? Male Female How old is your child? __________ years Is your child Hispanic or Latino?
Yes No I don’t know
What is your child’s race? (check all that apply)
White Black or African American Alaska Native or American Indian Asian Native Hawaiian or other Pacific Islander Other (please specify): ___________________ Decline
What is the highest grade or level of school YOU have finished?
I didn’t go to school 8th grade or less Some high school but did not graduate High School graduate or GED Some college / vocational or technical school Graduated from college, graduate school Other: (please specify): __________________
What language do you speak most at home?
English Spanish Cape Verdean Creole Haitian Creole Portuguese Mandarin
Cantonese Arabic Urdu Other: (please specify):
__________________
What is your zip code? ______________________________
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During the past 14 days (that is, during the past fourteen 24 hour periods that include daytime and nighttime), on how many days did your child have any asthma symptoms, such as wheezing, coughing, tightness in the chest, shortness of breath, waking up at night because of asthma symptoms, or slowing down of usual activities because of asthma? ____________days During the daytime in the past 14 days, how many days did your child have asthma symptoms such as wheezing, shortness of breath, or tightness in the chest, or cough? ____________days During the nighttime in the past 14 days, how many nights did your child wake up because of asthma symptoms such as wheezing, shortness of breath, or tightness in the chest, or cough? ____________nights During the past 14 days, how many times did your child have to slow down or stop his/her play or usual activities or missed school because of asthma, wheezing or tightness in the chest, or cough? ____________times During the past 14 days (that is, during the past fourteen 24 hour periods that include daytime and nighttime), about how many days did your child use asthma rescue medicine (sometimes called a quick relief medication) such as albuterol, proventil, ventolin, Xopenex? ____________days During the past 14 days, about how many days did your child use asthma controller medicine (sometimes called a preventive medicine or a steroid inhaler) such as QVAR, Pulmicort, Alvesco, Flovent, Axmanex, Symbicort, Advair or Dulera? ____________days Has your child’s doctor or other health professional provided you with a written plan (action plan) to help you decide how to change your child’s asthma medicine in response to changes in his/her asthma?
Yes No I don’t know
The last time your child’s asthma got worse, did you use the written action plan to decide what medicines to use?
Yes No I don’t know
cgordon
Sticky Note
Option 4: No, child did not have symptoms of asthma during this time.
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In the past 6 months, how many TIMES has your child been admitted to the hospital for asthma? ____________times In the past 6 months, how many DAYS total has your child had to stay in the hospital for asthma? ____________days In the past 6 months, how many times has your child gone to an emergency department because of asthma? ____________times In the past 6 months how many times has your child gone to the doctor’s office or clinic for the urgent treatment of worsening asthma symptoms? ____________times
In the past 6 months, how many times has your child gone to a non-urgent (routine) asthma visit with the primary care physician, asthma specialist or nurse? ____________times In the past 6 months, how many work or school days have you or another adult caregiver missed because of your child’s asthma? ____________days In the past 6 months, how many days of childcare or school has your child missed because of asthma? ____________days not applicable
Has your child received a flu shot or FluMistTM in the past 12 months?
Yes No I don’t know
cgordon
Sticky Note
Option 4: No, child has an egg allergy.
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PEDIATRIC ASTHMA CAREGIVER’S QUALITY OF LIFE QUESTIONNAIRE
This questionnaire is designed to find out how you have been during the last week. We want to know about the ways in which your child’s asthma has interfered with your normal daily activities and how this has made you feel. Please answer each question by placing a check mark (X) in the appropriate box. You may only check one box per question. DURING THE PAST WEEK, HOW OFTEN:
All of the Time
(1)
Most of the Time
(2)
Quite Often
(3)
Some of the Time
(4)
Once in a While
(5)
Hardly Any of the Time
(6)
None of the Time
(7)
QL1. Did you feel helpless or frightened when your child experienced cough, wheeze, or breathlessness?
1 2 3 4 5 6 7
QL2. Did your family need to change plans because of your child’s asthma?
1 2 3 4 5 6 7
QL3. Did you feel frustrated or impatient because your child was irritable due to asthma?
1 2 3 4 5 6 7
QL4. Did your child’s asthma interfere with your job or work around the house?
1 2 3 4 5 6 7
QL5. Did you feel upset because of your child’s cough, wheeze, or breathlessness?
1 2 3 4 5 6 7
QL6. Did you have sleepless nights because of your child’s asthma? 1 2 3 4 5 6 7
QL7. Were you bothered because your child’s asthma interfered with family relationships?
1 2 3 4 5 6 7
QL8. Were you awakened during the night because of your child’s asthma?
1 2 3 4 5 6 7
QL9. Did you feel angry that your child has asthma? 1 2 3 4 5 6 7
6
DURING THE PAST WEEK, HOW WORRIED OR CONCERNED WERE YOU:
Very, Very Worried/
Concerned
(1)
Very Worried/
Concerned
(2)
Fairly Worried/
Concerned
(3)
Somewhat Worried/
Concerned
(4)
A Little Worried/
Concerned
(5)
Hardly Worried/
Concerned
(6)
Not Worried/
Concerned
(7)
QL10. About your child’s performance of normal daily activities?
1 2 3 4 5 6 7
QL11. About your child’s asthma medications and side effects?
1 2 3 4 5 6 7
QL12. About being over-protective of your child? 1 2 3 4 5 6 7
QL13. About your child being able to lead a normal life?
1 2 3 4 5 6 7
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Six Month Caregiver Follow-up Questions What is your relationship to this child?_____________________ Have you moved since our last contact? Yes new zip code___________________ No During the past 14 days (that is, during the past fourteen 24 hour periods that include daytime and nighttime), on how many days did your child have any asthma symptoms, such as wheezing, coughing, tightness in the chest, shortness of breath, waking up at night because of asthma symptoms, or slowing down of usual activities because of asthma? ____________days During the daytime in the past 14 days, how many days did your child have asthma symptoms such as wheezing, shortness of breath, or tightness in the chest, or cough? ____________days During the nighttime in the past 14 days, how many nights did your child wake up because of asthma symptoms such as wheezing, shortness of breath, or tightness in the chest, or cough? ____________nights During the past 14 days, how many times did your child have to slow down or stop his/her play or usual activities or missed school because of asthma, wheezing or tightness in the chest, or cough? ____________times During the past 14 days (that is, during the past fourteen 24 hour periods that include daytime and nighttime), about how many days did your child use asthma rescue medicine (sometimes called a quick relief medication) such as albuterol, proventil, ventolin, Xopenex? ____________days During the past 14 days, about how many days did your child use asthma controller medicine (sometimes called a preventive medicine or a steroid inhaler) such as QVAR, Pulmicort, Alvesco, Flovent, Axmanex, Symbicort, Advair or Dulera? ____________days Has your child’s doctor or other health professional provided you with a written plan (action plan) to help you decide how to change your child’s asthma medicine in response to changes in his/her asthma?
Yes No I don’t know
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The last time your child’s asthma got worse, did you use the written action plan to decide what medicines to use?
Yes No I don’t know
In the past 6 months, how many TIMES has your child been admitted to the hospital for asthma? ____________times In the past 6 months, how many DAYS total has your child had to stay in the hospital for asthma? ____________days In the past 6 months, how many times has your child gone to an emergency department because of asthma? ____________times In the past 6 months, how many times has your child gone to the doctor’s office or clinic for the urgent treatment of worsening asthma symptoms? ____________times
In the past 6 months, how many times has your child gone to a non-urgent (routine) asthma visit with the primary care physician, asthma specialist or nurse? ____________times In the past 6 months, how many work or school days have you or another adult caregiver missed because of your child’s asthma? ____________days In the past 6 months, how many days of childcare or school has your child missed because of asthma? ____________days not applicable
Has your child received a flu shot or FluMistTM in the past 6 months?
Yes No I don’t know
cgordon
Sticky Note
Option 4: No, child did not have symptoms of asthma during this time.
cgordon
Sticky Note
Option 4: No, child has an egg allergy.
9
PEDIATRIC ASTHMA CAREGIVER’S QUALITY OF LIFE QUESTIONNAIRE
This questionnaire is designed to find out how you have been during the last week. We want to know about the ways in which your child’s asthma has interfered with your normal daily activities and how this has made you feel. Please answer each question by placing a check mark (X) in the appropriate box. You may only check one box per question. DURING THE PAST WEEK, HOW OFTEN:
All of the Time
(1)
Most of the Time
(2)
Quite Often
(3)
Some of the Time
(4)
Once in a While
(5)
Hardly Any of the Time
(6)
None of the Time
(7)
QL1. Did you feel helpless or frightened when your child experienced cough, wheeze, or breathlessness?
1 2 3 4 5 6 7
QL2. Did your family need to change plans because of your child’s asthma?
1 2 3 4 5 6 7
QL3. Did you feel frustrated or impatient because your child was irritable due to asthma?
1 2 3 4 5 6 7
QL4. Did your child’s asthma interfere with your job or work around the house?
1 2 3 4 5 6 7
QL5. Did you feel upset because of your child’s cough, wheeze, or breathlessness?
1 2 3 4 5 6 7
QL6. Did you have sleepless nights because of your child’s asthma? 1 2 3 4 5 6 7
QL7. Were you bothered because your child’s asthma interfered with family relationships?
1 2 3 4 5 6 7
QL8. Were you awakened during the night because of your child’s asthma?
1 2 3 4 5 6 7
QL9. Did you feel angry that your child has asthma? 1 2 3 4 5 6 7
10
DURING THE PAST WEEK, HOW WORRIED OR CONCERNED WERE YOU:
Very, Very Worried/
Concerned
(1)
Very Worried/
Concerned
(2)
Fairly Worried/
Concerned
(3)
Somewhat Worried/
Concerned
(4)
A Little Worried/
Concerned
(5)
Hardly Worried/
Concerned
(6)
Not Worried/
Concerned
(7)
QL10. About your child’s performance of normal daily activities?
1 2 3 4 5 6 7
QL11. About your child’s asthma medications and side effects?
1 2 3 4 5 6 7
QL12. About being over-protective of your child? 1 2 3 4 5 6 7
QL13. About your child being able to lead a normal life?
1 2 3 4 5 6 7
11
Twelve Month Caregiver Follow-up Questions What is your relationship to this child?_____________________ Have you moved since our last contact? Yes new zip code___________________ No During the past 14 days (that is, during the past fourteen 24 hour periods that include daytime and nighttime), on how many days did your child have any asthma symptoms, such as wheezing, coughing, tightness in the chest, shortness of breath, waking up at night because of asthma symptoms, or slowing down of usual activities because of asthma? ____________days During the daytime in the past 14 days, how many days did your child have asthma symptoms such as wheezing, shortness of breath, or tightness in the chest, or cough? ____________days During the nighttime in the past 14 days, how many nights did your child wake up because of asthma symptoms such as wheezing, shortness of breath, or tightness in the chest, or cough? ____________nights During the past 14 days, how many times did your child have to slow down or stop his/her play or usual activities or missed school because of asthma, wheezing or tightness in the chest, or cough? ____________times During the past 14 days (that is, during the past fourteen 24 hour periods that include daytime and nighttime), about how many days did your child use asthma rescue medicine (sometimes called a quick relief medication) such as albuterol, proventil, ventolin, Xopenex? ____________days During the past 14 days, about how many days did your child use asthma controller medicine (sometimes called a preventive medicine or a steroid inhaler) such as QVAR, Pulmicort, Alvesco, Flovent, Axmanex, Symbicort, Advair or Dulera? ____________days Has your child’s doctor or other health professional provided you with a written plan (action plan) to help you decide how to change your child’s asthma medicine in response to changes in his/her asthma?
Yes No I don’t know
12
The last time your child’s asthma got worse, did you use the written action plan to decide what medicines to use?
Yes No I don’t know
In the past 6 months, how many TIMES has your child been admitted to the hospital for asthma? ____________times In the past 6 months, how many DAYS total has your child had to stay in the hospital for asthma? ____________days In the past 6 months, how many times has your child gone to an emergency department because of asthma? ____________times In the past 6 months, how many times has your child gone to the doctor’s office or clinic for the urgent treatment of worsening asthma symptoms? ____________times
In the past 6 months, how many times has your child gone to a non-urgent (routine) asthma visit with the primary care physician, asthma specialist or nurse? ____________times In the past 6 months, how many work or school days have you or another adult caregiver missed because of your child’s asthma? ____________days In the past 6 months, how many days of childcare or school has your child missed because of asthma? ____________days not applicable
Has your child received a flu shot or FluMistTM in the past 6 months?
Yes No I don’t know
cgordon
Sticky Note
Option 4: No, child did not have symptoms of asthma during this time.
cgordon
Sticky Note
Option 4: No, child has an egg allergy.
13
PEDIATRIC ASTHMA CAREGIVER’S QUALITY OF LIFE QUESTIONNAIRE
This questionnaire is designed to find out how you have been during the last week. We want to know about the ways in which your child’s asthma has interfered with your normal daily activities and how this has made you feel. Please answer each question by placing a check mark (X) in the appropriate box. You may only check one box per question. DURING THE PAST WEEK, HOW OFTEN:
All of the Time
(1)
Most of the Time
(2)
Quite Often
(3)
Some of the Time
(4)
Once in a While
(5)
Hardly Any of the Time
(6)
None of the Time
(7)
QL1. Did you feel helpless or frightened when your child experienced cough, wheeze, or breathlessness?
1 2 3 4 5 6 7
QL2. Did your family need to change plans because of your child’s asthma?
1 2 3 4 5 6 7
QL3. Did you feel frustrated or impatient because your child was irritable due to asthma?
1 2 3 4 5 6 7
QL4. Did your child’s asthma interfere with your job or work around the house?
1 2 3 4 5 6 7
QL5. Did you feel upset because of your child’s cough, wheeze, or breathlessness?
1 2 3 4 5 6 7
QL6. Did you have sleepless nights because of your child’s asthma? 1 2 3 4 5 6 7
QL7. Were you bothered because your child’s asthma interfered with family relationships?
1 2 3 4 5 6 7
QL8. Were you awakened during the night because of your child’s asthma?
1 2 3 4 5 6 7
QL9. Did you feel angry that your child has asthma? 1 2 3 4 5 6 7
14
DURING THE PAST WEEK, HOW WORRIED OR CONCERNED WERE YOU:
Very, Very Worried/
Concerned
(1)
Very Worried/
Concerned
(2)
Fairly Worried/
Concerned
(3)
Somewhat Worried/
Concerned
(4)
A Little Worried/
Concerned
(5)
Hardly Worried/
Concerned
(6)
Not Worried/
Concerned
(7)
QL10. About your child’s performance of normal daily activities?
1 2 3 4 5 6 7
QL11. About your child’s asthma medications and side effects?
1 2 3 4 5 6 7
QL12. About being over-protective of your child? 1 2 3 4 5 6 7
QL13. About your child being able to lead a normal life?
