Slide 1 - North Carolina Asthma by hilen

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									In-home Environmental Assessments:
A Key Component of a Comprehensive
  Asthma Management Initiative for
         Medicaid patients

    Elizabeth Cuervo Tilson, MD, MPH
         Karla Theobald, RN,CCM
              Jason Dunn, RS
            Learning Objectives
   Learn about the presence and functions of
    Community Care of North Carolina Networks

   Understand how the assessment of environmental
    triggers compliments an Asthma Management
    Initiative

   Understand the elements of an environmental
    assessment for asthma triggers
   Overview of
Community Care of
  North Carolina
    (CCNC)
           Medicaid

  Carolina Access ($1 PMPM)


Community Care ($2.50 - $5
PMPM)
        *Carolina Access II
        *Health Choice
                Primary Goals
   Improve the care of the Carolina Access
    Medicaid population while controlling
    costs


   Develop the local systems, partnerships,
    links needed to improve care
     Primary care, Public Health, Social Services,
      Hospitals, Community agencies, etc
    Community Care of North Carolina
Community Care Networks
          May 2008




 AccessCare Network Sites
 AccessCare Network Counties
 Access II Care of Western NC              Community Health Partners
 Access III of Lower Cape Fear             Northern Piedmont Community Care
 Carolina Collaborative Comm. Care         Partnership for Health Management
 Carolina Community Health Partnership     Sandhills Community Care Network
 Central Piedmont Access II                Southern Piedmont Community Care Plan
 Comm. Care Partners of Gtr. Mecklenburg   Community Care of Wake and Johnston Counties
 Community Care Plan of Eastern NC         Central Care Health Network
        CCWJC Key Program Areas
   Chronic Disease Management Initiatives
       Disease specific or co-morbid conditions
   Integration of Physical and Mental Health
   Prevention Initiatives
   Pharmacy Initiatives
   Access to Primary Care
   Support of IT Initiatives
   Nurse case management services
        Components of Disease Specific
                Initiatives
   Identification of Best Practice Guidelines and quality
    measures for standard of care
   Education and resources to practices that correspond
    to best practice guidelines
   Feedback to promote Continuous Quality
    Improvement
   Identification and case management of “high risk”
    patients
                           Asthma
   2007 NIH/NHLBI Guidelines for the Diagnosis and
    Management of Asthma
   Provider tools and support to facilitate
       Continued Care Visit with assessment of symptoms
       Assessment of environmental triggers
       Prescribing maintenance medicine for patients with Beta agonist
        overuse
       Providing written management plans (AMP)

   Data Feedback
       QI form - To facilitate more rapid cycle QI
       Annual Chart Review – Track progress and identify areas for
        improvement and resources
                                                                                          Asthma Triggers
Name: ________________________________ DOB:__________                         Try to stay away from or control these things:
                                                                              □ Exercise          □ Smoke, strong odors or spray
Doctor: ______________________ Date:___________________                       □ Mold              □ Colds/Respiratory infections
                                                                              □ Chalk dust/dust □ Carpet
Phone for Doctor or Clinic: _____________________________                     □ Pollen            □ Change in temperature
                                                                              □ Animals           □ Dust mites
Predicted/Personal Best Peak Flow Reading:_______________                     □ Tobacco smoke □ Cockroaches
                                                                              □ Food ________ □ Other ____________________
                                                 Use these controller medicines every day to keep you in the green zone:
    1. Green – Go
     Breathing is good.                         Medicine:        How much to take:         When to take it:□ Home
     No cough or wheeze.                                                                                    □ School
                                                 _________________________________________________________________
     Can work and play.
                                                 _________________________________________________________________




Or Peak Flow ______ to ______ (80-100%)          5-15 minutes before very active exercise, use □ Albuterol____________(puffs).
                                                 Keep using controller green zone medicines everyday.
    2. Yellow – Caution
                                                 Add these medicines to keep an asthma attack from getting bad:
                                                 Medicine                 How much to take            When to take it
                                                 Albuterol               □ 2 puffs by inhaler        □ May repeat every
                                                    or                   □ 4 puffs by inhaler          20 min up to 3 doses
        Coughing               Wheezing          ________                □ with spacer, if available   in first hour, if needed
                                                                         □ by nebulizer
                                                 If symptoms DO NOT improve after first hour of treatment, then go to red zone.

                                                 If symptoms DO improve after first hour of treatment, then continue:
                                                 Albuterol             □ 2 puffs by inhaler             □ Every 4 - 8 hours
    Tight Chest        Wakes up at night              or               □ 4 puffs by inhaler               for _______ days
                                                  _________           □ with spacer, if available
Or Peak Flow ______ to ______ (50-80%)                                □ by nebulizer
                                                 ______________________________, _____times a day for ______days □ Home
                                                      (oral corticosteroid) (how much)                           □ School

                                                 Call your doctor if still having some symptoms for more than 24 hours!
                                                 Call your doctor and/or parent/guardian NOW!
    3. Red – Stop – Danger                       Take these medicines until you talk with a doctor or parent/guardian:

     Medicine is not helping.                   Medicine:                How much to take:            When to take it:
     Breathing is hard and fast.                Albuterol                □ 2 puffs by inhaler         □ May repeat every
     Nose opens wide.                               or                   □ 4 puffs by inhaler           20 minutes until
     Can’t walk.                                _________                □ with spacer, if available    you get help
     Ribs show.                                                          □ by nebulizer
                                                 ______________________________, _____times a day for ______days □ Home
     Can’t talk well.
                                                  (oral corticosteroid) (how much)                                □ School

                                                 Call 911 for severe symptoms, if symptoms don’t improve, or you can’t reach
Or Peak Flow ______ (Less than 50%)
                                                 your doctor and/or parent/guardian.


                                    WHITE – PATIENT          YELLOW – CHART          PINK – SCHOOL
         Case Management

 Identify   high risk patients

 Provide    case management
   Confirm   link with Primary Care Provider
   Education
   Linking with community resources
    (e.g. environmental assessments)
          Environmental Assessments
          as part of Asthma Initiative
   Started in 2006
       Re-affirmed by 2007 NIH guidelines

   Partnership between Wake County Environmental
    Services, Wake County Human Services, and CCWJC
   Links home assessments for asthma triggers with
    nurse case management services
   Initial pilot experience (August „06 to Nov „07)
   Current Initiative (August „08 – present)
              Initial pilot experience
                  (August ‘06 to Nov ’07)
   12 homes evaluated for asthma triggers
   Medicaid claims data evaluated 2 years pre-intervention and
    21 months post-intervention for 9 children
   Average number of asthma triggers – 4
   Average number of positive changes made - 4.4
   Average savings per child - $3196 due to lower ED, Clinic,
    and Hospital costs
   Total savings - $28,761
   Informed modifications for current initiative
     Modifications for Current Initiative
   New Environmental Specialist position (0.5 FTE dedicated)
       Wake County Human Services and Wake County Environment Services

   Increased frequency of assessments
       Goal – 2 per week, currently 25 homes

   Revised trigger assessment, follow up, and patient education
    forms
   Developed Database -tracks data 1 year pre and post assessment
   Tracking Measures: Demographics, Trigger assessment,
    Medication use, Supplies given to family, Trigger modifications made
    by the landlord and the patient, ED/hospital/PCP visits and costs
              Operationalizing of Case
                   Management
   Identification of patients
       Hospital Admissions, Emergency Visits, Direct PCP
        Referrals and Medicaid Claims Data

   Interventions for all Asthma patients
     Medicaid claims review to assess PCP/Specialty links,
      ED and Hospital use and prescription medication refill
      history
     Telephonic Asthma assessment for determination of
      educational and environmental needs
         Qualifications for in-home
        Environmental Assessments
   ALL Asthma patients are offered in-home
    assessments

   Intense focus is placed on patients that have:
     poor Asthma literacy and control
     poor medication compliance

     indicated an environmental concern (pests, mold,
      fumes, etc)
             Coordinating the
        Environmental Assessment
   Assessments are offered on specific days and
    times and a shared calendar is utilized between
    Case Management and Environmental
    Specialists to coordinate availability
   Pharmacy Home medication report is obtained
    by Network Pharmacist
   Current prescribed regimen is obtained from
    PCP/Specialist
    Details of in-home Assessments
   RN Case Managers provide general Asthma
    education on medications, triggers and control
   Mattress and pillow encasings are provided
   RN and Environmental Specialist work to
    determine any other environmental needs (roach
    containment, HEPA vacuum)
   Asthmatic Children receive an Asthma Backpack
   Environmental Specialist inspects home for
    possible triggers
          Post Assessment Reports
   A detailed report is provided to parent that
    includes findings of assessment

   A detailed report is provided to PCP that
    includes:
     findings of assessment
     education and supplies provided

     recommendations made by Environmental Services

     Pharmacy Home report
                         Follow up
   A repeat home visit by RN Case Manager at 6 weeks to
    assess compliance with recommendations made by
    Environmental Services. Any recommended supplies are
    given at this time (e.g. Hepa Vacuum, food containers, etc)
   Phone call at 6 months for detailed Asthma assessment
    (including adherence to environmental recommendations)
   Home Visit by RN Case Manager at 1 year for Asthma
    Assessment (including adherence to environmental
    recommendations)
   All patients receive quarterly Asthma educational mailings
    Protocol for Asthma Assessment
   Greeting/Introduction to Client and Family.
   Gather Information about environmental factors that
    client or family believe influences asthma events.
   Conduct asthma trigger assessment of home.
   Discuss findings of assessment with family.
   Provide educational literature about noted triggers.
   Prepare and send assessment reports to clients.
   Complete and send repair recommendation letters to
    landlords. ( For facility repairs beyond clients control)
Equipment/Methods of Assessment
   Visual evaluation of client/family home to
    identify triggers (Interior and exterior)
   Use of hydrometer to determine relative
    humidity throughout home. (Important for
    mold/moisture and dust mites)
   Use of flashlight to determine cleaning,
    ventilation, and pest problems.
     Environmental Asthma Triggers
      Evaluated during Assessments
   Dust mites
   Chemical Irritants
   Pest
   Second Hand Smoke
   Mold/Excessive Moisture
   Combustion By Products
   Warm Blooded Pets
   Other (Factors specific to that assessment)
    Categorization of Asthma Triggers
             for Assessment

   Contributing factors present

   Contributing factors not present

   Client based factor

   Landlord based factor

   Both client and landlord based factor
       Wake County Environmental Services and Community Care of Wake &
                             Johnston Counties

                            Environmental Asthma Trigger Assessment

Patient ID #

Location Address

City                                State NC               Zip


   1. Dust mites: Contributing factors present n/a Factors not present
      Observations:


   2. Chemical Irritants: Contributing factors present n/a Factors not present
      Observations:


   3. Pest: Contributing factors present n/a Factors not present
      Observations:


   4. Second Hand Smoke: Contributing factors present n/a Factors not present
      Observations:


   5. Mold/ Excessive Moisture: Contributing factors present n/a Factors not present
      Observations:


   6. Combustion By Products: Contributing factors present n/a Factors not present
      Observations:


   7. Warm Blooded Pets: Contributing factors present n/a Factors not present
      Observations:

   8. Comments:


Assessment conducted by:                                           Date:


Nurse Case Manager:
       Wake County Environmental Services and Community Care of Wake &
                             Johnston Counties

                                 Asthma Trigger Assessment Follow-up

Patient ID #

Location Address

City                                State NC            Zip


Assessment Follow up visit:
Date:
1. Dust mites:                    Factors corrected     Factors corrected     Factors corrected
                                  Partially corrected   Partially corrected   Partially corrected
                                  Factors unchanged     Factors unchanged     Factors unchanged
2. Chemical Irritants:            Factors corrected     Factors corrected     Factors corrected
                                  Partially corrected   Partially corrected   Partially corrected
                                  Factors unchanged     Factors unchanged     Factors unchanged
3. Pest:                          Factors corrected     Factors corrected     Factors corrected
                                  Partially corrected   Partially corrected   Partially corrected
                                  Factors unchanged     Factors unchanged     Factors unchanged
4. Second Hand Smoke:             Factors corrected     Factors corrected     Factors corrected
                                  Partially corrected   Partially corrected   Partially corrected
                                  Factors unchanged     Factors unchanged     Factors unchanged
5. Mold Excessive Moisture:       Factors corrected     Factors corrected     Factors corrected
                                  Partially corrected   Partially corrected   Partially corrected
                                  Factors unchanged     Factors unchanged     Factors unchanged
6. Combustion By Products:        Factors corrected     Factors corrected     Factors corrected
                                  Partially corrected   Partially corrected   Partially corrected
                                  Factors unchanged     Factors unchanged     Factors unchanged
7. Warm Blooded Pets:             Factors corrected     Factors corrected     Factors corrected
                                  Partially corrected   Partially corrected   Partially corrected
                                  Factors unchanged     Factors unchanged     Factors unchanged
# of tenant dependant triggers
changed
# of Landlord dependant
triggers changed

Notes/Comments:



Follow up conducted by:                                       Date:
Thank you!

								
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