Vol. 12 •Issue 9 • Page 52
Breathe Easy and Live Well
Community-based Approach Brings Asthma Education to People Where They Live, Attend School or Work
New treatments have made asthma a disease that should be completely manageable. Adults should be able to work and lead normal lives. Children shouldn’t miss school, nor be unable to play sports. Most of all, no one should die from asthma. Yet, between 1980 and 1994, asthma prevalence in the United States increased by 75 percent, and the death rate rose by 56 percent.1
Members of the Durham County Asthma Coalition (DCAC) believed that if they could bring health care education to people where they live, attend school or work, they could make a difference in this rate. Their efforts in Durham County, N.C., focused on improving lives and helping to prevent asthma exacerbation, as well as the long-term sequelae of untreated asthma.
The DCAC’s organized approach to the care of asthma patients replaces crisis management, which is the mode of care many patients receive. They strive to achieve an accurate diagnosis, the formation of a logical plan of treatment, and consistent follow-up of the patient in the clinic, school and community.
A COUNTYWIDE EFFORT
In 1997, a Fullerton Foundation grant brought together health care leaders from Durham County to discuss community health problems. The groups had never worked together despite their common concerns and overlapping patient populations.
These leaders identified asthma as one of the most significant concerns, with too many children missing numerous school days. A North Carolina School Asthma Survey in 2000 found that students with asthma were 37 times more likely to miss school than their classmates.2
Adults and parents of children with asthma were missing work, patients couldn’t afford medications or weren’t properly using their medications, and far too many patients were using emergency departments or urgent care facilities to receive asthma care. The DCAC formed to provide a multidisciplinary approach to focus on these problems and improve asthma disease management in Durham County.
County statistics played a part in many of their decisions as an asthma coalition. Durham County has a population of 223,314. The inner-city population is largely low-income and black, with a rapidly increasing Hispanic population (7.6 percent of the total population). Up to 12 percent of Durham’s 13,000 Medicaid patients have been diagnosed with asthma.
The DCAC recruited its volunteer membership from across the county. All health care disciplines were included, with representation from the two county hospitals, Duke and Durham Regional; the Lincoln Community Health Center, which cares for the majority of uninsured and lower-income families in the county; and local adult and pediatric primary care practices. The Durham County Public Health and Social Services Departments, the School Nurses Association, the North Carolina Chapter of the American Lung Association, and the Durham County Pharmacists’ Coalition also played important roles in the coalition.
VISION AND MISSION
Early in its inception, the DCAC decided on a simple vision: “To enable all Durham County residents with asthma to breathe easy and live well.” Its mission was to facilitate the collaboration of health care providers and community organizations to improve the health and well-being of people with asthma.
In May 1998, the DCAC planned its kickoff event, Asthma Awareness Day. More than 100 volunteers, numerous local celebrities and an Olympic athlete with asthma were on hand to educate more than 150 people about the disease.
One of the coalition’s goals was to attack many of the most entrenched problems in asthma management. DCAC members wanted to provide a self-management model and to focus on patient education and access to care. Many patients don’t understand how to control their disease, so the coalition developed patient education materials, written at a fourth-grade reading level, in English and Spanish.
Because some citizens can’t afford medical supplies, the coalition solicited donations of medications for needy patients and convinced insurance companies to change policies that made it difficult for patients to get what they needed. Most insurers now pay for peak flow meters and spacers twice a year.
Inconsistency and lack of communication among clinics and hospitals meant that many patients were receiving disjointed care or conflicting advice. The coalition standardized asthma management in Durham County, working from the National Heart, Lung, and Blood Institute’s Guidelines for the Management of Asthma.3 DCAC members developed a set of provider resource cards with references and teaching aids.
These educational materials were made available to all members of the coalition thanks to donations from several pharmaceutical companies and private citizens. At every training session for health care providers, the DCAC provided materials to all participants — along with an asthma training kit that included various inhaler and spacer devices. These participants then used the kits in their practices as a patient teaching tool.
While most interventions target only patients, the coalition decided to focus on training everyone who came in contact with the patient: respiratory therapists, physicians, nurses, nurse practitioners, physician assistants, residents, school health nurses and school teachers, pharmacists and even office staff.
As one DCAC volunteer put it, “A receptionist should be able to recognize when someone is wheezing and can’t breathe.” By ensuring that everyone in contact with an asthma patient understands the disease, it becomes less likely that early warning signs of an asthma exacerbation will be missed. Even the front desk staff can take a few minutes to ask patients if they have been taking their medicine or waking up at night due to asthma.
TRAIN THE TRAINER
It would be impossible for a volunteer group made up of providers working full-time jobs to touch every patient in the county. Therefore, the DCAC made a decision to train all personnel working in primary care practices. As everyone who could potentially interact with patients became more informed, they could make a greater impact on the management of patients’ asthma.
The DCAC members’ initial approach was to go to various points of care to see how asthma patients were being managed in each facility. They soon realized what was needed in these areas: basic updates on asthma, appropriate knowledge and use of medications and devices, and information about how to develop asthma action plans. This grassroots effort to go out to spread the word and educate eventually created the “train the trainer” approach.
In the first six months, the coalition trained 191 physicians in primary care practices, urgent care clinics and emergency departments. The coalition created a multidisciplinary team of asthma experts who volunteered to teach asthma management basics at every primary care practice in Durham County. They tailored the sessions to meet the needs of each office.
A key component of this train the trainer program is proper inhalant technique. It reviewed the latest in asthma care using the step-wise approach.3 DCAC trainers distributed patient education materials and incorporated hands-on demonstration into every teaching session.
They found that simply showing providers the proper inhalant techniques wasn’t enough; a return demonstration was necessary to assure proper patient teaching. They were amazed at the number of staff who didn’t teach appropriate techniques to their patients, if any teaching occurred at all. Patients often received prescriptions without any instruction about how to administer the medication.
The problem of inadequate medication knowledge was the impetus for the development of another training program. Understanding the importance of the pharmacist as a key member of the asthma care team, one member founded a pharmacist coalition that led to the development of a 36-hour continuing education program for pharmacists.
Participants who successfully completed the program earned a “certificate in asthma management.” The program consisted of a lecture and hands-on didactic educational sessions focusing on the appropriate use of medications and asthma. Durham County pharmacists were one of the first groups to be trained. The effort has since certified more than 200 pharmacists statewide.
Several coalition members felt the need to become identifiable experts in asthma care. They were training hundreds of providers through the train the trainer program but wanted proven credibility as educators. Fifteen DCAC members completed a six-month distance-learning course to receive a “diploma in asthma care” issued by the National Respiratory Training Center (NRTC).
The NRTC, a nonprofit organization based in the United Kingdom, has been a key player in the alliance to improve the education and training of health care providers in asthma disease management.
To date, the NRTC has trained almost 200 health care professionals in asthma disease management in North Carolina alone. Five members of the coalition continued their education and now are trainers for the NRTC courses.
MAKING A DIFFERENCE?
A retrospective look at data from Duke University Medical Center revealed that adult asthma admissions and outpatient visits to Duke Hospital markedly improved after the DCAC’s project was implemented. In the first three years of the coalition’s existence, admission volume decreased by 41 percent, length of stay decreased by 25 percent, emergency department utilization decreased by 10 percent, and cost decreased by 33 percent.4
The pediatric data weren’t as promising, reflecting no significant decrease in average length of stay, cost or emergency department visits in that period of time. Although the data didn’t show improvement in children, they did highlight a major problem and lead to new solutions.
Asthma disproportionately affects low-income, inner-city residents. A look at the patients seen at Duke with a diagnosis of asthma revealed that more than 75 percent of inpatient admissions and nearly 80 percent of emergency department visits came from patients who lived in four ZIP codes representing Durham’s low-income, inner-city residents.5 Many poor, predominantly black neighborhoods with a high proportion of uninsured and Medicare and Medicaid patients reside in these areas.
Asthma’s rising incidence in this population of predominantly black and Hispanic patients is apparent in the statistics of Lincoln Community Health Center. Asthma ranked eighth among the top 30 problems encountered at Lincoln Community Health Center in 2001.4
BUILDING ON ALLIANCES
To take better care of these patients, Duke and its community partners created two programs based on the idea of doing whatever it takes to help patients follow their primary care provider’s instructions. Many patients need help arranging transportation, purchasing medications and understanding how to take medications. The programs are called Promising Practices and the Durham Community Health Network (DCHN).
Promising Practices was launched in February 2000 to help patients in the four high-risk ZIP codes. The program sends health care practitioners into patients’ homes to help them control asthma, diabetes and hypertension with the goal of increasing health status and decreasing emergency care. The program also offers free disease screenings and health classes in the community. Duke University, the Kate B. Reynolds Foundation, the Duke Endowment and GlaxoSmithKline, among others, provide the funding.
Similarly, the Durham Community Health Network, a state Medicaid demonstration project established in 1998 by Lincoln Community Health Center, Duke and the Durham County Health and Social Services Departments, goes to great lengths to improve the health care of Medicaid recipients. The network’s social workers assist patients in securing transportation and help teach patients appropriate decision-making skills. Health educators are employed to assist with health education of this population.
The DCAC assisted in training many of the health care workers who visited families in their homes. This extensive training enabled workers to identify the best way to help patients understand their triggers and work to eliminate trigger exposure.
During training sessions, DCAC members taught social workers how to understand asthma management plans and help improve compliance. Bilingual literature and asthma action plans created by the DCAC provided the necessary guidance for educating the patients. Medications provided through patient assistance programs aided the patients who were underinsured.
Duke and DCAC asthma experts also offer continuing education for many physicians, on topics such as new medications and when to refer to an asthma specialist. A number of physicians from rural counties across the state have partnered with asthma experts to shadow them during their asthma care clinic visits. This allows a health care provider to gain more insight into the advances in asthma care on a firsthand basis.
Follow-up studies are showing significant improvements in asthma management across Durham County. The latest hospital data show that the number of DCHN patients with asthma admitted to Duke and Durham Regional Hospitals between 1999 and 2001 dropped from 207 to 104, a 50 percent decrease. During this same period, asthma-related emergency department visits to both hospitals for DCHN patients dropped from 149 to 70, a decrease of 53 percent.5
KEYS TO SUCCESS
The many health care providers involved with the DCAC attest to the coalition’s work and its effect on changing practice and improving asthma disease management in the county. DCAC members have supported other counties in the surrounding area by providing educational assistance and sharing their experiences. Many positive efforts across the state continue to evolve from the grassroots efforts that started five years ago.
DCAC has been able to network with various alliances and coalitions to help establish and maintain standards of asthma care. The key to the group’s success is communication and involvement among all health care disciplines.
Members have put aside their differences and built on the strengths of each person. Support also lies in securing funding for training, educational materials, and even supplies and medications for patients, whether from the pharmaceutical arena, grant money or public monies.
The largest identifiable barrier to productivity within the coalition is that a few key people perform the bulk of the workload. These professionals have a true passion for the effort yet also have full-time jobs. The group must find a way to engage the interest of the entire group and not allow the burden to fall on a minority. This will require creativity on the part of the entire group to identify each person’s strengths and capitalize on them for the good of the team.
1. Asthma mortality and hospitalization among children and young adults — United States, 1980-1993. MMWR. 1996;3(45):17.
2. Asthma in North Carolina: The North Carolina School Asthma Survey, 1999-2000. North Carolina Department of Health and Human Services, 2001.
3. National Institutes of Health. NHLBI National Guidelines for the Management of Asthma. Available from: URL: www.nhlbi.nih.gov/guidelines/asthma/index.htm
4. Data collected with help from the Department of Community & Family Medicine, Duke University Health System. Inpatient admissions/ED visits at Duke University Medical Center from 1996 through 2002.
5. Data collected with help from the Department of Community & Family Medicine, Duke University Health System. Inpatient admissions/ED visits at Durham Regional Medical Center and Duke University Medical Center from 1999 to 2000.
Mahaffey and Steele are pediatric nurse practitioners at Duke University Health System in Durham, N.C. Altman is an adult nurse practitioner at the same facility.