OUR INTERVENTION

Our Vision: Interventions to Improve Education and Care

The vision of IMPACT DC begins with the notion that effective longitudinal asthma care is a broad continuum that involves many parties.  At the center of this model is the patient who interfaces with his/her family, PCP, hospital, ED, retail pharmacist, insurance case manager, and school nurse.

Our vision continues with the novel idea that the ED can and should be a critical and integral part of this continuum, particularly for children who use the ED frequently and are poorly connected with their PCPs and other sources of care.

Our Intervention:

The IMPACT DC Asthma Clinic is a unique ED-based asthma care source that has operated continuously at Children’s National Medical Center since April 2002.  It sees children who are heavily dependent on EDs for episodic care, providing a comprehensive source of asthma education, medical care, and care coordination designed to steer them towards healthier lives and more effective primary longitudinal asthma care.

We see children within 2 weeks of ED visits for acute exacerbations for a 90-minute visit where they meet with an asthma educator and a physician.  While highly individualized and based on a shared dialogue with the family and the patient, the clinic’s curriculum is well scripted and highly reproducible.  Taking advantage of the “teachable moment” that naturally occurs after the crisis of an ED visit, our clinic staff focuses on the three key elements of the Consensus Guidelines for asthma care developed by the National Institutes of Health:

1.  Medical Care

• Education on the basic physiology of asthma with emphasis on its chronic nature
• Completion of an individualized Medical Action Plan
• Prescription of Controller Medications, as indicated by protocol
• Device teaching (spacer, diskus, nebulizer), as indicated
• Education on self-monitoring (by symptoms and/or peak flow measurement)
• Provision of a peak flow meter and/or spacer, as indicated

2.  Environmental Modification/Trigger Control

• Education on the role of the environment and triggers in asthma
• Specific education on the creation of a “safe sleep zone”
• Provision of pillow covers
• Tailored education on the following, as individualized for the family:

-Tobacco smoke

-Dust

-Molds

-Pests

-Pets

3.  Care Coordination

• Education on the role and importance of longitudinal asthma care with a primary care provider

The multiple activities of the IMPACT DC Asthma Clinic are valuable in themselves, but coordination with primary care physicians (PCPs) and others in the care continuum is among the most crucial.  This linkage between the ED and these caregivers represents an expanded role for the ED in which its activities are seen in the context of the broader systems of care for chronically ill children. To achieve such care coordination, we provide multiple services designed to improve and strengthen linkages between all those providing asthma care for the child in order to improve outcomes.  These activities include:

• Creation of an individualized patient report (with an embedded digital photograph of the child) which is forwarded to the patient’s primary care physician, managed care asthma case manager, and school nurse via fax and/or mail, as well as to the patient and family.
• Direct phone communication between the clinic physician and the PCP when required.
• Scheduling of a follow-up PCP appointment within 4 weeks of the clinic visit
• Scheduling follow-up appointments with the PCP and, as required, with sub-specialists who will be providing further evaluation and treatment.
• Completion of school forms sufficient to allow child to receive reliever and controller medications in the school from the school nurse when appropriate

Our program is uniquely positioned to facilitate care coordination by leveraging existing relationships within CNMC, particularly the District’s School Nurse Program and the Goldberg Center for Community Pediatrics.  In fact, CNMC is the administrative center of the School Nurse program in DC, and the Medical Director, Joseph Wright, MD, is a staff physician in the ED at CNMC.  Working closely with Dr. Wright and his administrators, we have been able to provide the school nurse of each patient within the IMPACT DC program with an individualized asthma care plan for use while they are in school.

Similarly, for children without an identified primary care source, we have been able to work with the financial counselors at CNMC and with the Goldberg Center to facilitate enrollment in Medicaid Managed Care and identification of a new primary care provider with the Children’s primary health care system, a system providing more than 50% of the primary care to Medicaid recipients in the District.

Over the period from April 2002 to August 2004, we rigorously studied this model of care in a prospective randomized clinical trial that has recently been accepted for publication in Archives of Pediatrics and Adolescent Medicine, a JAMA publication. It achieved several clinically and statistically significant outcomes:

• A greater than 100% increase in the use of controller medications
• A nearly 50% reduction in subsequent ED visits
• Sustained improvements in numerous measures of quality of life.

Having validated the efficacy of our model, our next goal is to refine and to expand it, bringing even more partners into the process of reducing asthma morbidity among disadvantaged children.