Even with all the latest treatment and medications available, over 3000 people die each day in the United States from Asthma. Asthma cannot be cured, but it can be managed with proper prevention and treatment.1
More Americans than ever before say they are suffering from asthma. It is one of this country’s most common and costly diseases.1 Major hospitals all over the U.S. are seeing patients with asthma in the emergency department (ED) and some are hospitalized over and over again. Many people wait until they are having an exacerbation to seek treatment rather than use preventive measures such as a controller medication on a daily basis, avoiding triggers and monitoring their symptoms.
Asthma Fast Facts
Every day in America:
• 44,000 people have an asthma attack.
• 36,000 kids miss school due to asthma.
• 27,000 adults miss work due to asthma.
• 4,700 people visit the emergency room due to asthma.
• 1,200 people are admitted to the hospital due to asthma.
• 9 people die from asthma.
Courtesy of Aafa.org
Some hospital EDs have developed protocols and asthma action plans that include the use of medications and patient education upon discharge. Most use the asthma guidelines supported by the National Heart, Lung, and Blood Institute (NHLBI) Expert Panel Review-3 to develop these protocols and quality measures.2 While this has improved patient care to some extent, it has not made significant changes in asthma outcomes – patients are still not following up with physicians for ongoing asthma management, refilling their controller asthma medication or following their asthma action plans. In a study looking at 30 children’s hospitals, asthma quality measures were evaluated and the investigators found that treatment in the hospital improved asthma care, but once discharged it was unlikely the patient/family would receive a follow-up visit.4 It is a challenge to evaluate patients after discharge and often, make a follow-up appointment seems less urgent from the family perspective once the child feels better.
St. Christopher’s Hospital for Children in Philadelphia, Pa., conducted a study utilizing a nurse practitioner and social worker at an after-hospital asthma clinic (AH-A Clinic) for follow-up asthma care for children older than two years old. Patients were seen in the clinic 7-10 days post discharge. Culturally correct education was administered, financial barriers identified, referrals made for additional social support, and medications were reviewed with the patient and family. The study found that patients seen at the clinic were less likely to be readmitted to the hospital within 30 days.3 There are many studies such as this that show different chronic disease models garner improvement, but a perfect model has yet to be identified. An emerging model that holds great potential is a model using the respiratory therapist (RT) as an asthma patient navigator. RTs have already proven to be very effective in providing asthma care and patient education; therefore, expanding their role in the asthma care model is obvious.
Asthma Navigator
Results from previous studies from major university hospitals have shown that it is very challenging to track and provide ongoing care for asthma patients that are discharged from either the ED or the inpatient hospital. Several years ago Baylor University Medical Center in Dallas , Texas, obtained funding for an asthma navigator to assist in the transition of care for patients admitted with the diagnosis of asthma. The idea stemmed from cancer navigator programs that have shown to be very successful in meeting the needs for patients, families and hospitals in making sure the patient is receiving the necessary care. An asthma navigator has a similar role to that of a case manager but has much more hands on and ongoing patient follow-up.
The asthma navigator model was designed for an RRT who is also certified as an asthma educator.5 The skillset required for such a position includes the following:
• patient assessment, both physical and history,
• diagnostic testing,
• allergy testing,
• patient education,
• patient self-management skills,
• medication management, including delivery devices, and
• home environment assessment.
They must know the NHLBI Asthma Guidelines and be able to work within protocols and decision trees. The asthma navigator must be a good communicator with patients of all ages and different cultures, physicians and other healthcare providers. Critical thinking skills are needed to determine the plan of care for each individual patient and for problem solving.
Baylor’s program was implemented with the asthma navigator seeing patients who were identified by the hospital as high risk patients, usually those who had multiple hospitalizations, ER visits and were not able to control their asthma. If the asthma navigator didn’t meet with the patient prior to discharge, he would contact the patient within 72 hours after discharge. Other times, the asthma navigator would visit the patient while still in the hospital so they could connect with the patient and begin asthma education immediately. It was also a time to get a contract signed by the patient stating they would return for follow-up care with the asthma navigator who would see the patient in an outpatient clinic. Having that initial visit while in the hospital made it easier for both the patient and clinician to identify concerns and barriers, and make the first follow-up appointment. These inpatient meetings gave the asthma navigator a little more time to help the patient master self-management asthma skills. Patients also received an asthma toolkit to take home that included a peak flowmeter, a valved-holding chamber to be used with a metered dose inhaler, and an asthma action plan that described in detail what actions the patient was to take based upon peakflow readings and asthma symptoms.5 Another tool patients leave the hospital with is the new mindset; they are now responsible for their asthma management and take ownership through self-management.
Follow-up phone calls are made weekly by the asthma navigator to each patient to discuss any issues the patient may be having that would prevent him from following his plan of care. Going into the program, administrators and clinicians believed that if patients had the right tools and had access to affordable medications, they would be able to control their asthma and stay out of the hospital. However, the barriers to healthcare that people deal with on a daily basis are more than most can imagine. Patients’ socioeconomic standing can have a huge impact on their ability to access clinics and afford the right medications – and that is where the social worker comes in as a very important player on team in the continuum of care. The team approach is very valuable and beneficial for improving patient outcomes for overall asthma care, but having the navigator to constantly evaluate the situation and determine the next steps is what makes the program successful. Baylor saw improvement in care and a decrease in hospital readmissions soon after the asthma navigator model was implemented.5 The next step for the asthma navigator is to make regular home visits to evaluate the home environment and observe the patient there.
Many hospitals and clinics have been using an asthma educator model for years, which is an integral part of the expanded asthma navigator role. The asthma educator’s certification exam from the National Asthma Educators Certification Board (NAECB) identifies clinicians who have the ability to assess and evaluate; provide patient and family education; and make decisions for the best asthma management for individuals. For those interested in becoming a certified asthma educator, the NAECB and the American Association for Respiratory Care (AARC) provide an exam preparation course.6,7
RTs Rule
Career opportunities for RTs are endless. The asthma navigator is just one of many new models that will help promote best care and meet the challenges we all face with hospital readmissions and reduced reimbursement. However, as time has shown, as our roles change, we transform.
Mary Hart, MSHCA, RRT, AE-C, FAARC, is director of clinical education, assistant professor, Department of Respiratory Care, School of Health Professions, University of Texas Health Science Center San Antonio.
References
1. Asthma and Allergy Foundation, Asthma Facts and Figures, www.aafa.org
2. National Heart, lung and Blood Institute, Guidelines for the Diagnosis and Management of Asthma (EPR-3).
www.nhlbi.nih.gov/guidelines/asthma/www.nhlbi.nih.gov/guidelines/asthma/.
3. Steinfeld J,et al. Hospital readmission rates of patients who gave attended the after hospital asthma (A-HA) clinic, 10.1164/ajrccm-conference.2012.185.1_MeetingAbstracts.A4076.
http://www.atsjournals.org/doi/abs/10.1164/ajrccm-conference.2012.185.1_MeetingAbstracts.A4076
4. Homer CJ. Improved quality of asthma care has not reduced readmission rates to hospitals, ED. JAMA. 2011,
http://www.healio.com/pediatrics/allergy-asthma-immunology
5. Hart MK, Hernandez G, Millard M. Asthma patient navigator program helps high risk asthma patients gain better control of their asthma. AJRCCM. 2012.
10.1164/ajrccm-conference.2012.185.1_MeetingAbstracts.A2879. http://www.atsjournals.org/doi/abs/10.1164/ajrccm-
conference.2012.185.1_MeetingAbstracts.A2879
6. National Asthma Education Certification Board. Asthma Educator Course. www.Naecb.com
7. American Association for Respiratory Care. Asthma Educator Course. www.aarc.org
