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Pediatric Asthma in Rural Wisconsin

VIEWS: 18 PAGES: 98

									Pediatric Asthma in
Rural Wisconsin
Cause and Effect in Patient Care:
By Amanda Kuehnle, Adrian Sproul,
and Dana Sox
Presentation Overview

OUTLINE


   River Rapids Health Care System
   Interdisciplinary Communication
   Accessibility of Care
   Patient Communication
   Community Awareness
   Conclusions
River Rapids Health
Care Systems:
River Rapids Objectives
   Safe: avoiding injuries to patients from the care that is intended to
    help them.
   Effective: providing services based on scientific knowledge to all
    who could benefit, and refraining from providing services to those
    not likely to benefit.
   Patient-centered: providing care that is respectful of and
    responsive to individual patient preferences, needs, and values, and
    ensuring that patient values guide all clinical decisions.
   Timely: reducing waits and sometimes harmful delays for both
    those who receive and those who give care.
   Efficient: avoiding waste, including waste of equipment, supplies,
    ideas, and energy.
   Equitable: providing care that does not vary in quality because of
    personal characteristics such as gender, ethnicity, geographic
    location, and socioeconomic status.



                                           -IOM, Crossing the Quality Chasm
RRHCS- River Rapids
   Hospital, attached          Staffed during the day
    clinic, and nursing         On-call evenings,
    home                         weekends, and
   25 beds                      holidays
   Not-for-profit              Charge nurse covers
   CLIA-certified               ED, physician on call
    laboratory on site          Nine physicians- eight
   New ED wing                  family practice and one
   Pleasantville Regional       internal medicine
    Medical Center 40           Two Pharm.D.s
    miles south
The Pasco Clinic
A Satellite of River Rapids
Pasco, Wisconsin
A Demographic
   Population~ 900
   Rural community in Corlett
    County
   Low crime rate
   Median household income~
    $32,000
   Increasing Somali immigrant
    population working at the
    poultry plant (about 4% right
    now)
Crossing the Quality Chasm
                 Ten Rules for Redesign

 1. Care is based on continuous healing relationships.
 2. Care is customized according to patient needs and values.
 3. The patient is the source of control.
 4. Knowledge is shared and information flows freely.
 5. Decision making is evidence-based.
 6. Safety is a system property.
 7. Transparency is necessary.
 8. Needs are anticipated.
 9. Waste is continuously decreased.
 10. Cooperation among clinicians is a priority.


                                     -IOM, Crossing the Quality Chasm
Part I:
Interdisciplinary
communication
And Then There Were 5…
Interdisciplinary communication
as a root cause of unmanaged
asthma
―The delivery of care often is overly
complex and uncoordinated,
requiring steps and patient
―handoffs‖ that slow down care and
decrease safety‖
                  - Crossing the Quality Chasm
Interdisciplinary Communication
                                                            No social
     Unmanaged                       Appointment with     worker consult
       Asthma                        allergist not made
                                                                            No change
                                                                             at home
                                     Pharm.D leaves
    Four ED visits                   message about                 No change in
                                      corticosteroid:              drug therapy
                                       Not returned
       Albuterol
     nebulizations                    Medical records              ED Visit #5:
 and/or hospitalization                never sent to                 Unable to
                                        Pasco Clinic              obtain medical
                                                                    records at
    No Pharm.D.                                                   ED admittance
      consult

                                                                Non-peds trained
                          Difficult intubation
                                                                   MD paged
Anoxic Brain Injury
Failure to Act

RRHCS:
   ―has two Pharm.Ds on staff to work with physicians, and
    provide education and ongoing education for chronic diseases,
    such as asthma‖ (p.3, ¶2)

   ―specialty physicians from the Pleasantville Regional Medical
    Center system travel to the River Rapids clinic for office visits
    on a monthly, bi-weekly, or weekly basis‖ (p.3, ¶4)

Corlett County Health Department:
 ―offers a visiting home public health nurse program for such
    services as…well-child care and childhood diseases.‖ (p.4, ¶2)
Failure to Act



   Why weren’t existing resources
    utilized?
Interdisciplinary Communication

   Barrier #1: The Medical Record
    – Medical Record:
           serves as a basis for planning patient care,
           documents communication between the health care provider and any
            other health professional contributing to the patient's care
           assists in protecting the legal interest of the patient and the health
            care providers responsible for the patient's care, and
           documents the care and services provided to the patient
                                          -http://en.wikipedia.org/wiki/Medical_record

    – Medical records were not shared between the child’s caregivers
      so NONE of the people treating Guleed were fully informed.

    – The records also did not indicate some important factors, like a
      smoker living in the home.
Interdisciplinary Communication

   Barrier #2: Specialist                             Current Model
    Consultations
    – Allergist, pharmacist, and
      social worker consults were         Care giver in                              No
      not utilized. Each could have         ED treats                        instruction or
      contributed to prevention.           respiratory                        any changes
                                             distress                          to therapy/
    – Example: By increasing the          with nebulizer                         lifestyle
      role of the pharmacist in a
      managed primary care setting,
      the patient will receive more
      complete pharmaceutical
      care.10
                                                            Unmanaged
    – The only way to end this cycle                        disease state
      is to institute interdisciplinary                    continues until
      intervention.                                        exacerbation
Solutions
Team Based Interdisciplinary Care
 Model: Cross Functional Team9
  –   Data:
       A clinical study to prove the hypotheses that team-based patient
        care improves Activities of Daily Living (ADL) on a psychiatric unit
       Tracking Indicators: GAF scores and ADL scores for patients, and
        Davis-Sacks survey for health care professionals.
        P-value= 0.9
       Findings: Interdisciplinary participation is the #1 effector of
        a patient’s outcome
       Patients who started the study being treated by a team had less
        impairment, and all patients with team care had significantly reduced
        impairment over time, compared to those treated by individuals.
Solutions
   How?
    1. A shared goal orientation—clear endpoints must be defined and
       prioritized within restricted resources and on the basis of community
       health needs, beliefs and values;

    2. collaboration—continuums of care must be built within which the defined
       endpoints can best be met without imposing one stakeholders'
       perspective over the other (i.e. they must have the freedom to follow
       their own dynamics and patterns in meeting those endpoints).
    –   ―continuous dialogue among collaborating partners to get and maintain a shared
        goal orientation, fed by local public health data on health needs and demands, is
        crucial for an integrated care arrangement to be successful‖

    –   Provide incentives for professionals working in a team

    –   Use surveys, patient outcome studies, and management ―spot-checking‖ in order to
        determine teamwork

    –   Create trust and reliability between team-members for effective patient care
Solutions

    How?
      – For more complete history and better
        interdisciplinary communication through the
        medical record, use ICF Checklist.
                International Classification of Functioning, Disability
                 and Health, formerly IDIDH-2
                Globally accepted, the ICF helps clinicians to
                 understand the spectrum of problems in functioning,
                 understand and measure health outcomes and look
                 beyond mortality and disease.11,13
(http://www.who.int/classification/icf)
 The ICF
Checklist:
Solutions
   Advantages11,13
          Comprehensive version allows for a multidisciplinary
           approach.
          Available in adult or pediatric.
          Includes body functions, body structures, activities and
           participation and environmental factors.
          Currently available in 6 languages.

   Disadvantages11,13
          Time consuming
          Some clinical and etiological factors cannot be
           fully/adequately described.
          Genetic factors cannot be well classified, as they are
           personal.
          Behavior smoking is not clearly included.
Costs Before Intervention




 Piecoro, L. et al. Health Services Research. 36(2). June 2001.
Cost Analysis
Average cost of ED visit with 3 nebulization
treatments4
                                                $1,808
Average cost of a 3 day hospital visit2
                                               $15,457
Ambulance ride to the hospital (avg.)
                                                  $400
3 week hospital stay (avg.)
                                               $54,096
Cost of 40 mile air transport
                                               $13,562
3 months Physical & Occupational Therapy
                                               $10,800
Guleed’s Total Cost of Care
                                               $96,123
Part II:
Accessibility of Care
Accessibility of Proper Care
   All Physicians are white,
   non-Hispanic; all speak
                                   Family told to travel
  English. 8 practice family
                                   40 miles to allergist        No knowledge of
     medicine, 1 internal
           medicine                                        insurance. Family pays for
                                                             medical expenses out of
                                                                     pocket
                                  Limited access to car
    No indication of use of
    travelling specialists to                                   Minimal Care and
             clinics.                                              Follow Up


                                   Hospital with lack
                                                                    Asthma
                                    of experience
                                                                     attack
                                    with pediatrics



                                                              ED Physician had
                                Difficult and prolonged        not intubated a
  Anoxic Brain Injury
Anoxic Brain Injury                    intubation              child in 5 years
Physician Recertification:
Accessing accurate knowledge
Does certification improve medical standards?
BMJ. 2006 Aug 26;333(7565):439-41.

The role of physician specialty board certification status in the quality movement.
JAMA. 2004 Sep 1;292(9):1038-43.


Incentivize Recertification
Cost of internal medicine boards: $950*
$950/7 years = $135/yr
$950/5 years = $190/yr
Increased cost to individual physician = $55/year
Incentivize by paying half of fee for those who recertify every 5
years: $475 every 5 years = $95/year, times 9 physicians (if all
participate)= $855/year
                                                             * http://www.residencyandfellowship.com/page12.html
Solutions
   Professional Development Assistance Program (PDAP)

   Based on McCullough Hyde Memorial Hospital, Oxford, OH
    – Designed to attract qualified personnel to the area.
            Rural areas traditionally have a difficult time attracting qualified staff members
             (medical personnel, interpreters, teachers, social workers, etc)
            Professional development program will pay for education/education related
             expenses in return for employment (at typical market rate) for a set period of
             time.
                –   Guaranteed job upon graduation
                –   Helps with rising costs of education
                –   Employers may target specific employees who are interested
                –   Plan to pay for continuing education, advanced degrees, etc.

    – Allows current personnel to expand their role
            May return for further education
            Career change
            New skills (such as learning a language or new trade)
Solutions- Professional
Assistance Programs
   5 Types of Programs16

    1. Service option
           Target medical students- option of service or repayment
    2. Scholarship
           Education is paid for. Obligation to serve with hefty penalties in case
            of default.
    3. Loan repayment
           Commit students at end of training. Help to pay back loans already
            accrued.
    4. Direct financial incentive
           Unrestricted funds upon signing
           The neediest settings tend to draw from this type of program
    5. Resident Support
           Support during residency with commitment for service at end of
            residency.
Solutions- Professional
Assistance Programs
   Effectiveness of Programs16

    – Obligated physicians worked in rural and underserved
      communities, smaller and poorer cities and towns with at-
      risk patient population.
    – Obligated physicians more often satisfied with their work
      and practices than non-obligated physicians
    – Obligated physicians felt a stronger connection to the
      community
    – Remained longer in service at first setting
    – 90.2% would enroll again in the same program
  Satisfaction of Professional
  Assistance Programs




Pathman, D. et. al ―Outcomes of States’ Scholarship, Loan Repayment, and Related Programs for Physicians.‖ Medical Care. 42 (6).
                                                      June 2004. p. 560-568.
Success of Programs
   5 Year Success with McCullough Hyde’s Program!

   Since its inception in 2001, PDAP has provided over $500,000
    to 39 individuals. Sixteen McCullough-Hyde employees have
    been able to advance their careers, and 23 aspiring health
    care workers have started their careers with McCullough-
    Hyde, because of PDAP funding.
Solutions- Community
Outreach
-   Outreach Program
-   Be accessible!
    - Office based visits, especially during work hours make
      compliance and consistency very difficult
         -   Remember basic family needs must be satisfied before advanced
             care, preventative care, anything that costs extra money, takes away
             from work (earning money)
    -   Home based services
    -   School based services
    -   Church based services
    -   Parent’s workplace
         -   Limits taking time off work
    - Transportation services
         -   To screenings, follow ups, anything involving medical care
         -   Volunteers from local colleges
Solutions
   Use previous patients to be ―navigators‖ for newer
    patients5,6
    – Establishes a connection within the community
           Relate to circumstances, culture, language barriers, etc
           May be able to help as translators
           Go with patients to appointments
              – Source of comfort
              – Diminishes fear
   Establish a link from initial care through follow up
    – Establish priority of need
    – Timely follow up
           Follow up office visits, medications
    – Rescreening
Part III:
Patient Communication
Fahmid Aan Sahlanayn?
Patient Communication
   “The need for clarity and understanding is paramount
    in any setting where people seek services. But in a
    hospital or clinic, life-and-death-decisions hinge on
    immediate, accurate communication. The
    consequences of poor communication can be
    devastating. Inaccurate history-taking, unnecessary
    testing, and misdiagnosis are just a few of the risks.”

   “The result of language barriers is often poor
    compliance, inappropriate follow-up and patient
    dissatisfaction."

    -Language Barriers in Medicine, Woloshin, et al, 1995 Journal of the
    American Medical Association 1995 Mar 1;273(9):
Patient Communication
  Diagnosed with         Parents given
     asthma at          written materials                         Grandfather lives with
   immigration              in English                            the family and smokes


      ED visit        Didn’t understand signs,
                      symptoms, and triggers
                        explained in English


   No interpreter         Importance of           Appt not made
                           allergist appt
                          not understood
                                                                     Unmanaged
  No demonstration                                                     disease,
   of albuterol MDI                                                  exacerbations


                                                 NP speaks
                       Playground            directly to child,
Anoxic Brain Injury
                          Event             parents uninformed
Patient Communication
   State and Federal Law:

    – Title VI of the Civil Rights Act of 1964 mandates ―linguistic
      accessibility to health care‖:
                 “No person in the United States shall, on ground of
                 race, color, or national origin, be excluded from
                 participation in, be denied the benefits of, or be
                 subjected to discrimination under any program or
                 activity receiving Federal assistance.”
                                                                   http://www.usdoj.gov/crt/cor/coord/titlevistat.htm

    – Title VI has repeatedly been interpreted by the federal Office of Civil
      Rights to mean that trained and qualified interpreters must be
      provided in health care and other settings.12

    – Minnesota law also requires public health care institutions to provide
      services to people with limited English proficiency.
                http://www.revisor.leg.state.mn.us/data/revisor/statutes/2005/15/441.html
Patient Communication
   Health Care Accreditation Systems12

    – The Joint Commission on Accreditation of Healthcare
      Organizations (JCAHO) requires hospitals to "have a way
      of providing for effective communication for each patient
      served"

    – the National Committee for Quality Assurance, which
      accredits managed care organizations, has stipulated that
      the provision of medical interpreters is essential to
      overcome the communication gap between providers and
      non-English-speaking patients.
Initial immigration
Processing: DHS Form I-693
Initial immigration
Processing: DHS Form I-693
Initial immigration
Processing: DHS Form I-693
Initial immigration
Processing: DHS Form I-693




           http://www.uscis.gov/GRAPHICS/FORMSFEE/FORMS/i-693.htm
Initial immigration
Processing: DHS Form I-693




           http://www.uscis.gov/GRAPHICS/FORMSFEE/FORMS/i-693.htm
Initial immigration
Processing: DHS Form I-693




           http://www.uscis.gov/GRAPHICS/FORMSFEE/FORMS/i-693.htm
Initial immigration
Processing: DHS Form I-693
        • Focuses almost exclusively on
        contagious & psychotic
        conditions.
        • Fails to screen for other chronic
        health conditions.
        • No screen for asthma




              http://www.uscis.gov/GRAPHICS/FORMSFEE/FORMS/i-693.htm
                  Initial immigration
                  Processing: I-693 instructions




http://www.cdc.gov/ncidod/dq/pdf/ti-civil.pdf
                  Initial immigration
                  Processing: I-693 instructions

                            •35 pages
                            •No mention of asthma,
                            diabetes or heart disease




http://www.cdc.gov/ncidod/dq/pdf/ti-civil.pdf
                         Initial immigration
                         Processing: DS-2035




http://www.cdc.gov/ncidod/dq/pdf/ti-civil.pdf



http://www.cdc.gov/ncidod/dq/pdf/ds-forms-instructions.pdf
                         Initial immigration
                         Processing: DS-2035




http://www.cdc.gov/ncidod/dq/pdf/ti-civil.pdf



http://www.cdc.gov/ncidod/dq/pdf/ds-forms-instructions.pdf
                         Initial immigration
                         Processing: DS-2035




http://www.cdc.gov/ncidod/dq/pdf/ti-civil.pdf



http://www.cdc.gov/ncidod/dq/pdf/ds-forms-instructions.pdf
                        Initial immigration
                        Processing: DS-2035


• Uses medically recognized classifications
• Includes some consideration of long term health care
needs and costs
• Still no mention of asthma or diabetes, or heart
disease.
http://www.cdc.gov/ncidod/dq/pdf/ti-civil.pdf



http://www.cdc.gov/ncidod/dq/pdf/ds-forms-instructions.pdf
Summary of Immigrant
Medical Exam:
• Neither I-693 nor DS-2053 screens for asthma or other
chronic conditions
•Medical in-processing of immigrants and refugees is
narrowly focused on exclusion criteria
Recommendation #1
•Standardize screening for asthma in refugee and
immigrant children at initial in-processing:
Recommendation #1
•Standardize screening for asthma in refugee and
immigrant children at initial in-processing:


 Form I-693
Recommendation #1
•Standardize screening for asthma in refugee and
immigrant children at initial in-processing:


 Form I-693




                                  Asthma
Health systems adapting to
changing demands:

The Example of
Schistosomiais…
                                Initial immigration
                                Processing:
- Awareness of Disease
Prevalence in developing
countries:
                                                                                              www.radiobridge.net/www/work/indexWORK2.html,,
                                                                                              http://www.tigr.org/tdb/e2k1/sma1/images/adult.jpg



                                                                SCHISTOSOMIASIS:
                                                                • Human parasitic disease
                                                                • Second only to malaria in public health
                                                                importance in tropical and subtropical areas.
                                                                • Endemic in 74 countries
                                                                • More than 200 million people infected.
                                                                • Infects a large proportion of under-14
                                                                children.

                                                                Source: WHO fact Sheet #115: Schistosomiasis


http://www.ncid.cdc.gov/travel/yb/utils/images/map4-10_lg.gif
                      Initial immigration
                      Processing:
- Awareness of Disease Prevalence in
developing countries:
 Presumptive treatment of schistosomiasis among Somali
 refugees:
 CDC tested for schistosomiais on 100 sera remains from pre-immigration
 medical screening from Somali refugees:

 • 69% tested positive for schistosomiasis1

 • Treatment (Praziquantel/Biltricide™) is cheap ($0.10 to $0.20 per tablet)2
 & effective (only two doses needed)

 • CDC recommends that all members of the Somali Bantu refugee group
 who have resettled to the U.S. should receive presumptive treatment for
 schistosomiasis
 1. http://www.cdc.gov/Ncidod/dq/refugee/somalibantu/presumptive_tx_recs_061305.htm
 2. http://www.stanford.edu/class/humbio103/ParaSites2005/Praziquantel/Praziquantel.htm#_Cost
          Recommendation #2

  Treat comorbid conditions to increase overall health of patient:



                • Be aware of Highly Prevalent diseases in country of origin
                • Be aware of current CDC treatment guidelines

                • Follow Current CDC guidelines and treat presumptively
                for schistosomiais

                • Physicians should be aware that serologic testing for children
                can be performed through CDC Division of Parasitic Diseases
                (770-488-7775).

                • Children under 4 years of age should not receive praziquantel.


http://www.cdc.gov/Ncidod/dq/refugee/somalibantu/presumptive_tx_recs_061305.htm
Treatment of Comorbid
conditions:
Implications for Asthma
management…
Patient Communication
  Diagnosed with         Parents given
     asthma at          written materials                         Grandfather lives with
   immigration              in English                            the family and smokes


      ED visit        Didn’t understand signs,
                      symptoms, and triggers
                        explained in English


   No interpreter         Importance of           Appt not made
                           allergist appt
                          not understood
                                                                     Unmanaged
  No demonstration                                                     disease,
   of albuterol MDI                                                  exacerbations


                                                 NP speaks
                       Playground            directly to child,
Anoxic Brain Injury
                          Event             parents uninformed
Patient Communication
  Diagnosed with         Parents given
     asthma at          written materials                         Grandfather lives with
   immigration              in English                            the family and smokes


      ED visit        Didn’t understand signs,
                      symptoms, and triggers
                        explained in English


   No interpreter         Importance of           Appt not made
                           allergist appt
                          not understood
                                                                     Unmanaged
  No demonstration                                                     disease,
   of albuterol MDI                                                  exacerbations


                                                 NP speaks
                       Playground            directly to child,
Anoxic Brain Injury
                          Event             parents uninformed
Patient Communication
  Diagnosed with         Parents given
     asthma at          written materials                         Grandfather lives with
   immigration              in English                            the family and smokes


      ED visit        Didn’t understand signs,
                      symptoms, and triggers
                        explained in English


   No interpreter         Importance of           Appt not made
                           allergist appt
                          not understood
                                                                     Unmanaged
  No demonstration                                                     disease,
   of albuterol MDI                                                  exacerbations


                                                 NP speaks
                       Playground            directly to child,
Anoxic Brain Injury
                          Event             parents uninformed
Patient Communication
  Diagnosed with         Parents given
     asthma at          written materials                         Grandfather lives with
   immigration              in English                            the family and smokes


      ED visit        Didn’t understand signs,
                      symptoms, and triggers
                        explained in English


   No interpreter         Importance of           Appt not made
                           allergist appt
                          not understood
                                                                     Unmanaged
  No demonstration                                                     disease,
   of albuterol MDI                                                  exacerbations


                                                 NP speaks
                       Playground            directly to child,
Anoxic Brain Injury
                          Event             parents uninformed
Patient Communication




Written & Spoken Translation…
                                  Patient Communication

                   Written & Spoken Translation




http://www.health.state.mn.us/divs/hpcd/cdee/asthma/schoolmanual.html
                                  Patient Communication

                   Written & Spoken Translation




http://www.health.state.mn.us/divs/hpcd/cdee/asthma/schoolmanual.html
Patient Communication



   What if written materials are
           unavailable?
Patient Communication

Collaborating with the private sector:



     Somali translation
     you can trust




                          http://www.appliedlanguage.com/languages/somali_translation.shtml
Patient Communication

Collaborating with the private sector:




http://www.appliedlanguage.com/languages/somali_translation.shtml
Recommendation #2

       Provide asthma screening checklists
       and action plans written in Somali
       through local schools.


Cost: Screening Checklists in Somali already available
from Minnesota State Dept. of Health
• Translation of asthma action plan to Somali: $175
• Printing and distribution costs: for 70 immigrants,
through local schools: $25
Patient Communication




  What if patients are not literate?
Patient Communication
   State and Federal Law:

    – Title VI of the Civil Rights Act of 1964 mandates ―linguistic
      accessibility to health care‖:
                    “No person in the United States shall, on ground of
                    race, color, or national origin, be excluded from
                    participation in, be denied the benefits of, or be
                    subjected to discrimination under any program or
                    activity receiving Federal assistance.”
                                                        http://www.usdoj.gov/crt/cor/coord/titlevistat.htm

    – Title VI has repeatedly been interpreted by the federal Office of Civil
      Rights to mean that trained and qualified interpreters must be
      provided in health care and other settings. (12)

    – Minnesota law also requires public health care institutions to provide
      services to people with limited English proficiency. http://www.revisor.leg.state.mn.us/data/
                                                                                 revisor/statutes/2005/15/441.html
Patient Communication
   State and Federal Law:

    – Title VI of the Civil Rights Act of 1964 mandates ―linguistic
      accessibility to health care‖:
                    “No person in the United States shall, on ground of
                    race, color, or national origin, be excluded from
                    participation in, be denied the benefits of, or be
                    subjected to discrimination under any program or
                    activity receiving Federal assistance.”
                                                        http://www.usdoj.gov/crt/cor/coord/titlevistat.htm

    – Title VI has repeatedly been interpreted by the federal Office of Civil
      Rights to mean that trained and qualified interpreters must be
      provided in health care and other settings.12

    – Minnesota law also requires public health care institutions to provide
      services to people with limited English proficiency. http://www.revisor.leg.state.mn.us/data/
                                                                                 revisor/statutes/2005/15/441.html
Recommendation #3

   http://www.medicalassistant.us/index.php




      Train at least two bilingual members of local Somali
      community as certified medical interpreters.


Cost: for completing accredited 6-8 week online certification
course:

• Training 3 people at $645/person = $1935

• Estimated PRN costs for community of 70 Somalis in RRHCS &
PASCO, Assuming 2hrs per person per year at $45/hr = $6300

                                               http://www.medicalassistant.us/index.php
          Recommendation #4:
          Video Based Learning




The effect of telepharmacy counseling on metered-dose inhaler technique among adolescents with
 asthma in rural Arkansas. Bynum et al , Telemed J E Health. 2001 Fall;7(3):207-17.
Recommendation #4:
Video Based Learning
Recommendation #4

   Demonstrate proper inhaler technique
   by video
Patient Communication:
Summary of costs
Training 3 Local Interpreters
                                             $1,935
Employing Local Interpreters for est.
140hrs/ year
                                             $6,300
Translating and distributing asthma
information sheets in Somali
                                               $200
Creating and Translating inhaler technique
video
                                               $400
Total estimated cost for enhancing
communication with Somali patients:
                                             $8,835
Part IV:
Community Awareness
Who Knew?
Lack of disease state awareness in
the community as a root cause of
the sentinel event
Community Awareness
    Guleed told his                Lack of
       teacher                   community                    No asthma education
   that cold makes              awareness of                  in place at the school
  his asthma worse                 asthma

                                                                    Teacher did not
       No specific                                               believe him; told him
   programs targeted      Lack of Cultural Awareness              to continue playing
      to immigrant
       population
                                                                    Exacerbation


                                                                 No albuterol MDI
                                                                 kept at school for
                                                                   emergencies



Anoxic Brain Injury    Ambulance ride                                  No immediate
                                                   collapse
                       to the hospital                                     relief
Community Awareness
& Support
   Although the Somalians constitute a
    growing population, no formal
    programs exist to help immigrant
    families adjust
   No asthma program is in place at the
    schools
Solutions- Outreach
programs
   Outreach Program
   Based on Mom’s Morning Out Program in Charleston, SC
    – Mothers are new immigrants5,15
        -   Feel isolated, trapped
        -   Language and cultural barriers
        -   Lack confidence, and fear disclosure (don’t want to appear
            incompetent)
        -   Need to work and support family
               - Providing food, shelter, more important than healthcare
               - Can’t take time off work
               - Overwhelming demands on time- no time to seek out additional
                  assistance
        -   No basic understanding of what resources are available to them

    - Recruit at school open houses, churches, workplaces
Program Objectives
   Primary Objectives
    – Language development
      for children and mothers
            School readiness
    – Provide health
      Information
            Normal development
            Screenings
            Accessibility
    –   Prevention
    –   Mental Health
    –   Dental Health              Mom’s
    –   Substance Abuse
                                  Morning Out
Solutions- Outreach
programs
-   Develop a support group
      -   Women who do not have any outside
          contacts have no idea what resources are
          available to them.15
      -   An outreach program similar to ―Mom’s
          Morning out‖ will provide information to the
          caregivers and steer them in the proper
          direction for medical care.
Solutions- The School
System
     The school system




    Centers for Disease Control and Prevention. Strategies for Addressing Asthma within a Coordinated School Health Program
Solutions- The School
System8
   Must be a team approach
   Emergency protocols in place
   Full time RN at school
   Have access to a consulting physician to the school
   Case management for students/families with
    frequent problems, absences, etc.
   Integration of asthma awareness and education
    into health programs
   Educate school staff on asthma basics,
    management, and emergency response as part of
    their professional development activities.
Conclusions:
What is this going to
cost me?
Original Costs:
Average cost of ED visit with 3 nebulization
treatments4
                                                $1,808
Average cost of a 3 day hospital visit2
                                               $15,457
Ambulance ride to the hospital (avg.)
                                                  $400
3 week hospital stay (avg.)
                                               $54,096
Cost of 40 mile air transport
                                               $13,562
3 months Physical & Occupational Therapy
                                               $10,800
Guleed’s Total Cost of Care
                                               $96,123
Cost of Recommendations:
Professional Development Assistance/ year
(interdisciplinary)
                                             $100,000
Training & Employing Local Interpreters &
translating asthma education materials:
                                               $8,835
Projected cost (per year) of drugs for
managed asthma (150/mos)
                                               $1800
Approximate cost of allergist appointment
                                                $235
Total Cost of Care of Intervention
                                            $110,870
Shelledy, David C. ―The effect of a pediatric asthma management program provided by respiratory therapists on patient outcomes and cost.‖
                                                   Heart and Lung. 2005; 34(6): 423-429.
References
1.   Henry, Richard L. ―Randomized controlled trial of a teacher-led asthma education
     program.‖ Pediatric Pulmonology. 38(6):434-42, 2004 Dec.
2.   Tatis V. Remache D. DiMango E. ―Results of a culturally directed asthma
     intervention program in an inner-city Latino community.‖ Chest. 128(3):1163-7, 2005
     Sep.
3.   Sapien, Robert E. Fullerton-Gleason, L. Allen, N. ―Teaching school teachers to
     recognize respiratory distress in asthmatic children.‖ Journal of Asthma. 41(7):739-
     43, 2004 Oct.
4.   Maley MA. Denz-Penhey H. Lockyer-Stevens V. Murdoch JC. ―Tuning medical
     education for rural-ready practice: designing and resourcing optimally.‖ Medical
     Teacher. 28(4):345-50, 2006 Jun.
     Zanchetta MS. Poureslami IM.
5.   Inman, Dianna. Williamson, Deborah. ―Mom’s morning out‖ presentation. MUSC
     Alliance for Hispanic Health Lecture. October 5, 2006.
6.   deArellano, Michael. Dept. of Psychiatry MUSC. ―Hospital Based Model for Patient
     Navigation.‖ MUSC Alliance for Hispanic Health Lecture. October 5, 2006.
7.   McCullough Hyde Memorial Hospital, Oxford, OH. Professional Development
     Assistance Program. http://www.mhmh.org/media/PDAP_Overview2006.pdf
8.   Centers for Disease Control and Prevention. Strategies for Addressing Asthma within
     a Coordinated School Health Program, with Updated Resources. Atlanta, GA: Centers
     for Disease Control and Prevention, National Center for Chronic Disease Prevention
     and Health Promotion, 2005. Available at:
     www.cdc.gov/HealthyYouth/asthma/pdf/strategies.pdf
References
9.    Alexander, Jeffrey. ―Cross Functional Team Processes and Patient Functional
      Improvement.‖ HSR: Health Services Research 40:5, Part I. October 2005, p. 1335-
      1355
10.   Hahn, N. Weart, W. ―The pharmacist's role in the optimal delivery of primary care in
      a managed care world‖ Pharmacy Practice Management Quarterly. 15(4):36-43, 1996
      Jan.
11.   World Health Organization. International Classification of Disease, Functioning, and
      Health. http://www.who.int/classifications/icf/en/
12.   Somali Translation and Interpreting.
      http://members.tripod.com/~Somali1/interpreter2.html
13.   Stucki, A; Stoll, T; Cieza, A; Weigl, M; Giardini, A; Wever, D; Kostanjsek, N; Stucki, G.
      ―ICF Core sets for Obstructive Pulmonary Diseases.‖ Journal of Rehabilitation
      Medicine, Supplement. 36 Supplement 44:114-120, 2004.
14.   TITLE VI OF THE 1964 CIVIL RIGHTS ACT.
      http://www.usdoj.gov/crt/cor/coord/titlevistat.htm
15.   Neufeld, A., Harrison M., Stewart, M., Hughes, K., Spitzer, D. ―Immigrant Women:
      Making Connections to Community Resources for Support in Family Caregiving.‖
      Qualitative Health Research. Vol. 12 (6). July 2002. 751-768.
References
16.   Pathman, D., Konrad, T., King, T., Taylor, D., Koch, G. ―Outcomes of States’ Scholarship, Loan
      Repayment, and Related Programs for Physicians.‖ Medical Care. 42 (6). June 2004. p. 560-568.
17.   De Arellano MA, Waldrop AE, Deblinger E, Cohen JA, Danielson CK, Mannarino AR.Community
      outreach program for child victims of traumatic events: a community-based project for underserved
      populations. Behav Modif. 2005 Jan;29(1):130-55.
18.   Shelledy, David C. ―The effect of a pediatric asthma management program provided by respiratory
      therapists on patient outcomes and cost.‖ Heart and Lung. 2005; 34(6): 423-9.
19.   Piecoro, L. et al. ―Asthma Prevalence, Cost, and Adherence with Expert Guidelines
      on the Utilization of Health Care Services and Costs in a State Medicaid Population.‖ Health Services
      Research. 36(2). June 2001.
20.   CDC Recommendations for presumptive treatment of schistosomiasis and strongyloidiasis among
      the Somali Bantu refugees, Available at:
      http://www.cdc.gov/Ncidod/dq/refugee/somalibantu/presumptive_tx_recs_061305.htm
21.   WHO fact Sheet#115: SCHISTOSOMIASIS: Available at:
      http://www.who.int/mediacentre/factsheets/fs115/en/index.html
22.   Minnesota Department of Health. ―Managing Asthma in Minnesota School. A manual and Training‖
      Available at: http://www.health.state.mn.us/divs/hpcd/cdee/asthma/schoolmanual.html
23.   Applied Language Solutions: Somali Translation: Available at:
      http://www.appliedlanguage.com/languages/somali_translation.shtml
24.   Bynum A, Hopkins D, Thomas A, Copeland N, Irwin C The effect of telepharmacy counseling on
      metered-dose inhaler technique among adolescents with asthma in rural Arkansas. TELEMED J E
      Health. 2001 Fall;7(3):207-17.
Acknowledgements
   Teri Lyn Herbert, MUSC Reference Librarian
   Dr. Ronald Nickel, Ph.D., College of Pharmacy Faculty
   Dr. Christopher Fortier, Pharm.D., MUSC Pharmacy Services
   Dr. Lynn Uber, Pharm.D., Outcomes Management Coordinator,
    MUSC Pharmacy Services

								
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