Vol. 19 •Issue 5 • Page 31
Is an Asthma Clinic Right for Your Hospital?
Clinics Can Benefit Patients, But They Need Time, Money and Research to Work
On paper, opening an asthma clinic might sound like a great idea. After all, asthma is a chronic condition that deserves plenty of attention and tender loving care; and RTs treat huge numbers of asthmatics every year. So the question remains: Why not open a clinic and give these patients the extra help and time that they need?
An asthma clinic may be right for your hospital, but opening one requires an investment in research, time and money. You must pay for it, staff it and promote it. And before you do anything, you must make sure your community needs the clinic in the first place.
Your Potential Patients
If you are a hospital thinking of opening an asthma clinic, the first thing you need to do is figure out your potential patient population, said Gary Halfhill, BS, RRT, AE-C, co-asthma manager of the Asthma Management Program at St. Rita’s Medical Center in Lima, Ohio. That program is open two days a week and staff see three to six patients a day.
How many patients with asthma are visiting your ER? How many are admitted into the hospital? Look at their lengths of stay. Look at frequent fliers, those who are constantly in the ER. It is these patients, in particular, whom you will be targeting.
In short, how much demand is there for a clinic? You don’t want to open a clinic that no one will use.
Philadelphia’s Thomas Jefferson University Hospital had two main reasons for starting its Asthma Center, a clinic that sees eight to 10 patients on the one day a week it is open. First, the hospital conducts a lot of asthma research, and the clinic anchors that by providing a well-documented population for study.
The hospital was also dealing with quite a few underserved asthma patients who were inadequately treated and using the ER for their primary care. “We saw a need for a clinic,” said James Zangrilli, MD, FACP, FCCP, pulmonologist and Asthma Center director.
When looking at your potential patient population, check the demographics carefully. Are you dealing with primarily young patients? What language do these potential patients speak?
If your facility is in a Spanish-speaking neighborhood, you are going to need a translator for your clinic, said Vincent Hutchinson, MD, allergist and medical director of the asthma clinic at New York City’s Harlem Hospital Center. The clinic there is open three days a week and schedules at least 75 to 80 patients a week, though many of these ultimately do not show up for appointments.
Staff, Equipment and Money
Once you have determined a clinic is needed, you must think carefully about how you are going to pay for it.
“You need to sustain it,” Hutchinson said. “People get grants, but grants run out.” Survey what kind of insurance coverage your potential patients have. Are they mostly Medicare, Medicaid or self-pay patients? You need to get an idea of how, or if, you will be reimbursed for services.
“We don’t turn a profit,” Halfhill said. In fact, because St. Rita’s Medical Center has made a commitment to education, the hospital does not charge for a patient’s first clinic visit, which focuses solely on education.
However, by decreasing ER visits and hospitalizations, St. Rita’s Asthma Management Program does reduce the hospital’s overall expenses. “We don’t make money, but we do save them money,” Halfhill said.
Staffing is an obvious expense. To staff its Asthma Center, Thomas Jefferson uses its existing pulmonary practice. Finding staff to work just one half-day a week at a clinic would be hard.
“I think (starting a clinic) is easier to do if you have an existing practice,” said Zangrilli, a physician with Jefferson Pulmonary Associates. “Starting from scratch would be difficult.”
Minimal Staffing Needs
Besides Zangrilli, the clinic has a medical technician, who performs skin tests and pulmonary function tests. A receptionist admits patients and makes appointments. All three work at the hospital’s pulmonary practice.
Three is the absolute minimum you need to open a clinic, Zangrilli said. It would also be nice to have someone like a respiratory therapist to focus solely on doing education.
The clinic at Harlem Hospital Center has a nurse practitioner available 9 a.m. to 7 p.m., five days a week, so patient questions can be answered at any time, even when the clinic’s three doctors aren’t holding office hours, Hutchinson said.
Additionally, remember that asthmatics are complicated patients, so you need to set up relationships with different disciplines, Zangrilli said. You will need access to an ear, nose and throat doctor who’s interested in sinus issues. You’ll need access to a speech therapist to handle vocal cord issues. You’ll need access to a psychologist or social worker to deal with stress and anxiety, which are asthma triggers.
In terms of staffing, the clinic at St. Rita’s is unusual in that it does not have a dedicated doctor. But it makes sure that patients coming through have a physician-approved asthma action plan when they leave.
To do that, the clinic’s two RTs come up with a proposed plan, which is then sent to the physician who referred the patient. The physician agrees or tweaks their recommendations and sends the plan back with his approval. “We work hand in hand with physicians,” Halfhill said. “We do the groundwork.”
In addition to clinicians, managers need to think of filling their clinics with equipment. Spacers, peak flow meters and nebulizers all need to be stocked. If you are dealing with poor patients who may not have insurance and may be unable to pay for even this basic equipment, you may want to find ways to obtain donations, Hutchinson said.
Promotion in the Community
Once staffing and equipment issues are figured out, you can’t just throw open your clinic doors and expect a long line to be waiting. The “Field of Dreams” mantra of “If you build it, they will come” does not automatically work, Halfhill said. You must do promotion.
Give talks in the community. Offer flexible hours that are convenient for potential patients. Speak with pediatricians, primary care doctors and adult and pediatric pulmonologists. Let them know you are there to educate and spend time with their troublesome patients.
Importantly, emphasize that you are not there to steal patients, Halfhill said. Your mission is to help, not to step on toes.
Establish credibility with potential referring docs. Following the National Institutes of Health asthma guidelines is one way to do that, Halfhill said. His clinic’s two RTs are certified as asthma educators, a fairly new avenue of certification open to therapists. “It shows I’m serious,” he said.
At this point, hospitals may be thinking they have covered all the bases needed to establish an effective clinic by planning for all these contingencies. But to offer truly comprehensive asthma care, hospitals may want to go one more step and provide a home component with their clinics.
Home Asthma Triggers
The home environment, after all, can play a major role in triggering an asthma attack. When Harlem Hospital Center was still seeing a high number of ER visits despite creating their specialized clinic, the facility linked up with Harlem Children’s Zone Inc., an organization that focuses on community-building activities.
The two formed a program called the Harlem Children’s Zone Asthma Initiative, said Hutchinson, the program’s medical director. The initiative focuses on asthma in a 24-block area of Harlem where the asthma rate among children is 30 percent.
The initiative conducts home visits. These include an intensive inspection looking for asthma triggers. Clinicians oversee the program, but community workers are the ones who do the visits.
Hutchinson recommended establishing similar partnerships for other asthma clinics trying to reach out into their patients’ homes. The combining of clinicians’ clinical expertise with the infrastructure of a community organization can make for a potent and efficient team. “You must have a home component,” he said.
Opening an asthma clinic can certainly be a lot of work; but if one is right for your facility, it can make a difference in the positive outcome of patient care. Halfhill remembered one patient whose asthma was out of control. In one year, the female patient had 20 ER visits and one hospitalization.
After coming under the watchful eye of the clinic, though, she reduced that number to six ER visits and zero hospitalizations over the course of a year.
John Crawford is a Philadelphia freelance writer.