Asthma InterventionAsthma Intervention

Asthma Project TeamAsthma Project Team

• Accurso, Kathy, Rochester Public School

• Ahern, Lois, Public Health

• Aleman, Marty, Public Health

• Baumbach, Shaylene, Public Health

• Beebe, Calvin E., Mayo Clinic

• Bock-Goodner, Cynthia, Mayo Clinic

• Donnal, T. M.D., Winona Health

• Frazier, Christa, Winona Health

• Gunderson, Margene, Public Health

• Hart, Lacey, Mayo Clinic

• Horton, Ian, Mayo Clinic

• Jensen, Dan, Public Health

• Juhn, Young J., M.D., Mayo Clinic

• Knoebel, Erin E., M.D., Mayo Clinic

• Lowe, David. M.D.; Olmsted Medical

• Martin, Erin L., Mayo Clinic

• McWilliams, Deb, M.D., Mayo Clinic

• O’Brien, Michael, Mayo Clinic

• Naessens, James, Sc.D., Mayo Clinic

• Ravikumar, Prajna, Mayo Clinic

• Targonski, Paul, M.D., Ph.D., Mayo Clinic

• Wellik, Mary, Public Health

• Williams, Linda M.D., Olmsted Medical

• Yawn, Barbara, M.D., Olmsted Medical

SE MN Beacon ImpactSE MN Beacon Impact

Using our experience with uni-directional sharing of AAP with schools and the community’s expertise in community based participatory work, we will design and develop a program to provide the child with asthma a “cocoon of care” at school, in organized activities and home, based on the healthcare home’s generated asthma action plan.

School aged children Asthma School aged children Asthma PrevalencePrevalence

Asthma is estimated

- to occur in 7% of school-age children nationally 1

- to occur in 12% of school aged children in Rochester, MN 2

1. CDC. Surveillance for Asthma --- United States, 1960--1995. MMWR 1998;47[No. SS-1]:1—28

2. Yawn BP, Wollan P, Kurland MJ, Scanlon P. A longitudinal study of the prevalence of asthma in a community population of school age children. J Pediatrics 2002;140(5):576-581.

School aged children: School aged children: Asthma ImpactAsthma Impact

• Poorly controlled asthma can affect – a child’s ability to exercise, – self-esteem, – school performance, – to poor school attendance.

• Asthma action plans can decrease preventable illness.

National Heart, Lung, and Blood Institute. 2007. National Asthma Education and Prevention Expert Panel report 3: guidelines for the diagnosis and management of asthma. Bethesda (MD): National Institutes of Health. Available from URL: www.nhlbi.nih.gov/guidelines/asthma/epr3/index.htm

Collaborative ExperienceCollaborative Experience

Community Collaborative Asthma Project in Olmsted County-2008

• Mayo

• Olmsted Medical Center

• Olmsted Public Health

• Rochester School District

Beacon ProposalBeacon Proposal

Extend the asthma action plan model to the 11-county region, augmented with standards-based HIE.

Sharing action plans for children with asthma can:

1.Reduce healthcare utilization

2. Improve school attendance

3.Reduce time parent misses work.

Care CoordinationCare Coordination

Includes processes of care coordination with providers, public health and schools.

Asthma MeasuresAsthma Measures

Future/Advanced Measures Preventative Care Utilization Appropriate Med Usage Inpatient/ED Utilization Acute attacks in school School Absenteeism

R&D Measures% electronic exchange

(school/provider)PROsOthers - TBD

Baseline Measures(Meaningful Use 5-40)% patients age 5-18

% w/documented Action Plan % w/Influenza Vaccine % w/pneumonia Vaccine

% of total ED Visits

COST – QUALITY – POPULATION HEALTH

AAP Expansion ProjectAAP Expansion Project

Leverage lessons learned and tools developed in Olmsted County Asthma Action Plan Task Force providing patient-centered care to ensure anyone who cares for a child with asthma has access to and understands that child’s AAP:

• Develop a consent process • Approved by schools and state• Templates are available• Process flow sheets created

SE MN Beacon will expand to ALL school districts: •School System AAP FAQs •Consent Form to Share Asthma Action Plan Template•Consent Form Process Flowsheet Template

School Personnel Education :•Access and understanding of AAPs for ALL personnel•When to Consider communication with the Provider & Parent

AAP Expansion ProjectAAP Expansion Project

11 – Counties; 47 School Districts Beacon – School Project Prioritization:Willingness to collaborate

Existing relationshipsAsthmatic student impact

Expansion NumbersExpansion Numbers

Intervention County (City)Student

PopulationEstimated Asthmatics

Year 1 - Target AAPs

(25%)

Year 2 - Target AAPs

(75%) Target Date

#Beacon Clinics in County

#School Nurses

AAP Process Expansion Dodge 3993 399 100 299 10-2011 1 4AAP Process Expansion Fillmore 3331 333 83 249 10-2011 4 3Computerized AAP Decision Support Fillmore (Chatfield) 483 48 12 30 12-2011 1 1AAP Process Expansion Freeborn 4673 467 117 350 10-2011 1 2AAP Process Expansion Goodhue 9529 953 238 714 10-2011 4 5AAP Process Expansion Houston 5152 515 129 386 10-2011 1 4AAP Process Expansion Mower 6030 603 150 452 10-2011 1 1Computerized AAP Decision Support Mower (Austin) 4092 409 102 306 12-2011 1 1AAP Process Expansion Olmsted 20707 2070 5176 1552 10-2011 8 9Computerized AAP Decision Support Olmsted 20707 2070 5176 1552 12-2011 8 9AAP Process Expansion Rice 9197 920 230 690 10-2011 1 2AAP Process Expansion Steele 6797 680 170 510 10-2011 1 2AAP Process Expansion Wabasha 4015 402 100 301 10-2011 2 3AAP Process Expansion Winona 5874 587 147 440 10-2011 4 3Computerized AAP Decision Support Winona (Winona) 3845 385 96 289 12-2011 4 3

AAP # school aged patients calculated by 2000 Census Zip code attendance w / averaged 10% asthma population projection

Practice Deep DivePractice Deep DiveMayo ClinicMayo Clinic

2583 "confirmed asthmatics“

administrative and medical record review

25% followed by asthma care manager

additional 511 "likely asthmatics" from administrative data

Total = 3094 (an estimated prevalence 12% = 3188 pts).

40% have an electronic Asthma Action Plan in CDM Reports,

73% live in Olmsted County.

29% of all primary care kids have triggered reporting rules (i.e., MN Community metric; includes AAP done on/after July 1, 2010). Of these, still need an "up-to-date" Asthma Action Plan on 380 (42%) … by 6/30/11

Technology PilotsTechnology Pilots

• Technology specifications created by the Asthma Action Plan Task Force Data Base pilot program – Resources to scale the infrastructure into the Beacon region

• Widespread implementation of a technology solution will take time – the magnitude of issues– proposed technology solutions– a strong emphasis on protecting the confidentiality and best interests

of patients

• The Pilot approach aims to generalize the technology approach through targeted school participation and lessons learned

R&D – Assessment ToolsR&D – Assessment Tools

Explore a standard measure and electronic format to allow for guidelines based assessment and intervention improving control for patients with asthma.

• APGAR

• ACT

Focus Groups

AAP Technology Pilots (exact locations TBD)

R&D Pilots (APGAR) (exact locations TBD)

Pilot InterventionsPilot Interventions

AAP Expansion Timelines

4/1/2010 6/4/2011

1/1/2011

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10/1/2010 4/1/2011

1/1/2011

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5/1/2010 - 7/31/2010Established cross-region

asthma focus project team

9/3/2010Baseline Asthma Measures reported

3/14/2011 - 5/31/2011AAP Process Expansion: -Preparing for AAP acceptance-School Workflow Process Mapping- Consent Process-Preparing for next school year

7/31/2010 - 12/1/2010- Identified schools and health care

facilities willing to participate in stage 1 pilot.- Communication channels through Public Health

2/4/2011 - 3/15/2011Flu Vaccine Letters

10/1/2010 - 12/31/2010- IRB Protocol submissions

for focus groups

1/28/2011Asthma Vaccinations reported

1/3/2011 - 3/15/2011- Conducted Focus Groups (nurses, parents, clinicians)

-Analysis & Results

12/4/2010 - 3/12/2011- AAP Process

Expansion Plans- Pilot Work

9/18/2010 - 12/1/2010Define Push/Pull requirements

7/2/2010 - 9/7/2010Review Olmsted Proj Specs

4/1/2011 - 6/1/2011Refine communication Technical requirements

Qualitative Study / Focus GroupsQualitative Study / Focus Groups

Olmsted County StatusOMC Pediatricians Completed OMC Family Med Completed OMC Nurses (1-1) Completed MCR Physicians Completed Rochester Private school staff In progressRochester Private school Parents In progressRochester public school staff In progressRochester public school parents In progressRochester public school adolescents In progressByron public school staff Completed Byron public school parents In progressByron public school adolescents In progress

Fillmore CountyOMC-Branch Office CompletedChatfield school staff ScheduledChatfield school parents In Progress

Mower CountyProvider - Austin In ProgressAustin public school staff In ProgressAustin public school parents In Progress

Winona CountyProvider CompletedSchool-861 Public schools & Charter DistrictIn ProgressParents In ProgressAdolescents In Progress

Identify perceived needs, and barriers and facilitators related to the wide spread use of asthma action plans for school children.

Groups of interest: •Parents of school aged children w/ asthma •School nurses & others that care for children with asthma in schools•School aged adolescents with asthma • Physicians / nurses who provide health care for children with asthma

Focus Group Prelim ResultsFocus Group Prelim ResultsClinic 1 nurses and physiciansClinic 1 nurses and physicians

• “AAP is important but one for school and home may be different.”• “It would be good to have feedback from the schools to know about students

how are having frequent problems.”• “Parents must be part of the loop on interchange.”• “AAPs must be updated yearly.”• “A system to routinely get to schools in way that is useable to schools is

nice---paper, email, pdf, etc.”• “AAPs must reflect correct practice not inappropriate local interpretations of

guidelines.”• “Caring for student with asthma could be much improved if three way

communication could be developed.”• “Will need to develop system to get information from schools and parents to

correct people in clinic.”

Survey Prelim ResultsSurvey Prelim ResultsClinic 2 nurses and physiciansClinic 2 nurses and physicians

• AAPs are an important tool for schools and families• It is important to evaluate whether AAPs make a difference in the care of

asthma in schools• It would be helpful to the care of patients with asthma to have

communications with schools (missed PE, sent home, child’s technique and understanding of disease)

• 90% agree with the concept that consistency in adhering to guidelines is needed

• Time to create the AAP is a constraint for physicians and nurse practitioners (80% no more than 3 minutes of time – preference to review, not create)

• Would like to know more about how the AAP is used at school and the training within the schools of those with access to the AAP

Focus Groups-School SitesFocus Groups-School Sites(School Nurse, Health office, Teachers & Coaches)(School Nurse, Health office, Teachers & Coaches)

• Knowing what to do with Student is Important– Asthma Action Plans are

useful to Health Office staff

– Coaches rely on 1st Aid Training to know what to do

• Issues– Inhalers are kept in Health

Office

– Communication of Changes in med order or plan

• Suggestions– Access to electronic

information would help

Parent InputParent Input

• Supportive of Improved Communication with Schools

• Want Paperwork Process simplified

• Asthma Action Plans are useful tools

• Not concerned about confidentiality & communication between provider & school as long as parent in the loop

Barriers / TA Team DiscussBarriers / TA Team Discuss

Problem: Despite it's name, the MN "Community Metric" for asthma (ages 5-50) is not really a "community" metric.

Specific example: Of the 2385 total Mayo patients that had a visit that would mean they are reported to the “community metric” for last portion of 2010, only 1602 had continuity care at Mayo.

Proposal by rejected solution: Exclude all asthma patients with addresses outside of the state and consider splitting those with medical home in the reporting site and outside of the reporting site.

Barriers / TA Team DiscussBarriers / TA Team Discuss

Problem: Quality metrics should be based on innovation and research that demonstrates their value and validity and not be biased by local “experts”. Specific example: The Minnesota Community Measurement Board

has publicly stated its refusal to provide waivers for Federally funded research. (MN Med Feb 2011) 

Solution: The MN Community Measurement Group needs to provide waivers for federally funded research programs dealing with quality improvement, metric development and testing and translational and dissemination work. These waivers need to be announced publicly.

– The waivers need to be broadly announced to patients, policy

makers, payers and providers. 

SE MN Beacon ImpactSE MN Beacon Impact

• Using our experience with uni-directional sharing of AAP with schools and the community’s expertise in community based participatory work, we will design and develop a program to provide the child with asthma a “cocoon of care” at school, in organized activities and home, based on the healthcare home’s generated asthma action plan.