Chapter Quality Network (CQN) Asthma Pilot Project Team Progress Presentation State Name: Alabama Practice Name: Bessemer Health Center Team Members: Dr. Iris Fancher Dr. Joni Gill Pamela Tartt Tiffany Holland

Progress Summary Bessemer Health Center Engagement of QI team and practice Pediatricians discuss findings and process daily. Both providers and QI team members participate on calls and entering data. Provider not on QI team actively participates and reviews outcomes and interacts with Pulmonary on our current status and concerns. 100% of immediate staff involved in some step of process and 70% highly engaged. PDSA planning and EQUIP reviewed –usually QI team but second provider participates.

Using Registry to Manage Asthma Population EMR will be used as registry for Jefferson County Department of Health. Registry formation to track chronic illnesses by Summer Encounter form contents with NHLBI asthma guidelines added to EMR to prepare for formation/population of registry and documentation of optimal asthma care measures since 11/2009. Current Asthma diagnosis and all Flu vaccines given can be tracked. 3 process measure components are in EMR/Medcin component. -validated instrument -Asthma Action plan given -stepwise approach

Using a Planned Care Approach to Ensure Reliable Care in Office Office Flow Diagram formatted Current changes in place and weak points determined and reexamined. CQN Encounter Form Used for all Bessemer Health Center asthma patients. 100% pediatric staff and providers engaged to make available. 90% of patients complete without difficulty (PDSA sampling) 100% complete when reviewed by staff with parent. Goal is to actively count the forms on daily basis. Improve on visual appeal.

Bessemer Health Center Encounter Form

Developing an Approach to Employing Protocols Practice wide asthma guidelines implemented NHLBI Asthma guidelines in table form in EMR(Asthma Template) Optimal care process measures included in EMR(accessible to all providers) Asthma Action Plan –Medications on AAP forms on EMR and can be selected (see file). Asthma Template in EMR Medcin(see file)

Asthma Action Plan

Asthma EMR Template

Providing Self Management support Patient Education materials available. Initially patient education included: MD Consult handouts; Asthma Handouts from NHLBI Pediatric Advisor Handouts Recent most positive response and ease for providers, nurses and patient families.

Providing Self Management support Recent most positive response and ease for providers, nurses and patient families: - Asthma Action Plan used to educate and teach meds. - Patient education packets “What is Asthma?”;(Cincinnati) “5 Important Things You Should Know About Asthma”;(MaineHealth) Asthma (MD Consult) Asthma Action Plan(includes asthma triggers)

% of patients with 1 or more asthma related ED visits within past 12 months

% of ED and urgent care visits have decreased from 35 to 15 % of samples. -attributed to a family of seven in which 6 have asthma ranging from mild to severe. - March 1 st month no one in that family hospitalized.

% of Patients with optimal asthma care

All asthma patients are assessed using simplified encounter form each visit. Stepwise approach using EMR asthma template. to identify treatment options and adjust therapy Written asthma action plan each visit reviewed and given to family. All patients greater than 6 months must be offered flu vaccine or document why not given.

% of patients 5 years or older where spirometry is scheduled to be tested or results obtained within last 1-2 years

Spirometry is an issue -Budgeting -Distance to Specialty clinic -Ability to initiate the process at a center that will close. -Billing allowed only once a year -staffing concerns to manage uniformity of procedure. - legal concerns -What if staff MD does not want to do spirometry yet it’s available in clinic? -medical concerns-what do you do with questionable data

% of patients 5 years or older where spirometry is scheduled to be tested or results obtained within last 1-2 years UAB may come Spring 2010 to test older pts. age 6 and older persistent asthma pts study. No improvement noted per EQUIP but active pursuit of answers ongoing.

% of patients in which self-management education materials(in addition to asthma action plan) are provided and explained to the family and patient.

% of patients in which self-management education materials(in addition to asthma action plan) are provided and explained to the family and patien t Multiple PDSAs to determine best way to present forms and hold family interest. Handouts as previously noted. Simplify and repetition with staff and patients to make sure handouts always given.

PDSA Cycles PDSA Title: Provide and explain self-management and education materials  Plan: Test 5 patients over 1 day period.  Do: Assess patient/family response to handouts.  Study: Interest of family in asthma information. One family left packet on table.  Act: Direct concerns to all family members and copy for caretakers. Visual appeal and simplify especially for milder asthma.

TEST 1 What:: Review education h/o. Who (population): asthma pts. Who (executes):MD,nurse. Where: Exam room When: 2/16/10 PD SA TEST 2 What:: Asthma handout Who (population): asthma pts Who (executes): Peds staff Where: Exam room When: all visits PD SA TEST 3 What: : asthma handout /packet Who (population): All asthma pts. Who (executes):Peds staff/MD Where: exam room When: during and after exam PD SA TEST 4 What: asthma h/o 1 pg to f/u pt Who (population): follow up Who (executes): MD/staff Where: exam room When: after exam PD SA TEST 1 What:: CQN encounter form Who (population): asthma pts. Who (executes): Clerk,nurse Where: EMR schedule flagged When: 9/2 PD SA TEST 2 What:: ID pt each AM Who (population): asthma pts Who (executes): LPN Where: EMR schedule When: 9/24 PD SA TEST 3 What: Adjust encounter message Who (population): asthma pts. Who (executes): Pam Tartt Where::Exam room When:9/28 PD SA TEST 4 What: Test Simplified encounter form Who (population): asthma pt Who (executes):MD/staff Where: exam room When: Review over 1 month PD SA TEST 1 What:: H/o review AAP (EMR) Who (population): all asthma pts Who (executes): MD Where: exam room When: each visit/ 11/09 PD SA TEST 2 What: New H/o tested AAP Who (population): asthma Who (executes): MD/staff Where: exam room When: 1/10/10 PD SA TEST 3 What: New AAP adjusted Who (population): asthma pts Who (executes): MD Where: exam room When: 2/10 PD SA TEST 4 What:: new AAP on EMR Who (population): asthma pts Who (executes): MD/staff assists Where: exam room When: 3/10 PD SA Provide asthma handoutsEncounter formsProvide written asthma plan PDSA Ramps

Scheduled Asthma patients identified daily by nurses; Need for Asthma encounter noted on each patient in EMR check-in time of visit. At time of patient check in, encounter form placed on patient routing slip by medical clerks and pass routing form and encounter to nursing staff. Nurses discuss form with patient answers questions and have form filled out questions Pt placed in exam room Nurse checks for completeness And offers flu vaccine. Nurse also note previous history of asthma or new patient and gives forms Encounter form placed in exam room door During the visit Asthma education Techniques and decision-making discussed with patient and further history noted. Stepwise Approach based on NHLBI guidelines. Appropriate specialty referrals, PFTs planned Asthma Action plan reviewed and given. Follow up discussed. MD/nurse reviews techniques of meds again Physicians place form in their office to enter data at later time and follow up appts made. Physician completes the form immediately after the visit and enters into EMR before signing off record. Office Visit - Prework During Office Visit Post Visit Activities Physicians and QI team review follow up and encounter.. Referrals and Follow –up appointments made by Medical clerk NO All necessary information on the form is entered into EQIPP and Registry (Work on EMR registry in progress). by physicians YES List of asthma patients generated. Letters generated for those needing flu vaccine otherwise. Review of EQUIP information with staff and QI team monthly Clinical Assessment Process Map – Paper Chart System

Key Learnings  Simplify.  Visual Appeal  Perform daily tasks in small repetitive steps.  “All improvement will require change; but not all change will result in improvement.”

Barriers and Successes Successful team effort Size of a large system can slow process but can also increase the opportunities for a more aggressive change. (Ex. Registry and budgets) Patient population- initially difficult to get involved in process. As patients follow up, they now actively participate in talking to parents about asthma and meds.

Barriers and Successes Goals met include % of patients with optimal asthma care % of patients with key asthma indicators used % of patients in which validated instrument used % of patients with reasons for lack of control % of patients with stepwise approach % of patients with flu shot % of patients with self management materials % of patients with f/u appts

Future Plans Registry planning process with Research and Policy department at Jefferson County Department of Health. Set up time for Pulmonary attending to come and give another presentation with staff and review current packet that we have available Further discussion on spirometry and will need information to request in budget by end of April. Plan to further simplify Encounter Form and Asthma Encounter form

Future Plans PDSAs More organized meetings with staff and monthly meeting with all staff to include CQN updates. More strategies to improve asthma control