Understanding and addressing asthma in Florida: the role of community health workers Shaláwa Triggs Florida Department of Health, Bureau of Chronic Disease Prevention 8th Annual FL CHW Summit – Orlando, FL September 15, 2018

Presentation Learning Objectives Participants will be able to: Understand asthma and the current burden Describe what happens during an asthma attack Describe best practices to treat and manage asthma Understand the CDC’s 6|18 Initiative Describe ongoing efforts in Florida to address and improve asthma

Burden of Asthma

What is Asthma? Asthma is a chronic disease of the airways that may cause: Wheezing Breathlessness Chest tightness Nighttime or early morning coughing Asthma is a chronic disease that involves inflammation of the lungs. Airways swell and restrict airflow in and out of the lungs, making it hard to breathe. The word asthma comes from the Greek word for “panting”. People with asthma pant and wheeze because they cannot get enough air into their lungs. Approximately 1 in 8 Florida adults and 1 in 5 Florida children have asthma. However, asthma is more common and more severe among children; women; low-income, inner-city residents; and African American and Puerto Rican communities.

CDC Vital Signs – February 2018 In addition to considerable impacts on quality of life, the economic cost of asthma is sizeable. Costs including direct medical costs (such as hospital admissions and the cost of pharmaceuticals) and indirect costs (such as time lost from work, school absenteeism, and premature death), weigh heavily on individuals, the health care system, and schools. https://www.cdc.gov/vitalsigns/childhood-asthma/index.html

CDC Vital Signs – February 2018 Children who were hospitalized  for asthma Percent (%) hospitalized, ages 0-17 years In 2003,  10% of children with asthma were hospitalized. In 2013,  5% of children with asthma were hospitalized. Children with asthma who missed school days Percent (%) missing school, ages 5-17 years In 2003, 61% of children with asthma missed school days. In 2013, 49% of children with asthma missed school days. Though asthma-related hospitalizations and missed school days were fewer in 2013 than in 2003, we still have a lot of work to do. https://www.cdc.gov/vitalsigns/childhood-asthma/index.html

CDC Vital Signs – February 2018 Here, you can see where the difference can still be made. Almost 70% of children with asthma are relying on a rescue inhaler for actual asthma attacks. Only 55% of them are using their long-term medication to keep their asthma controlled. And, out of the 55%, 25% of them aren’t using their controller medication regularly s prescribed. https://www.cdc.gov/vitalsigns/childhood-asthma/index.html

Asthma Attack

What Happens During an Asthma Attack? People with asthma have inflamed airways, making the airways swollen and very sensitive. Muscles around the airways tighten, causing a narrowing of the airways and reducing air flow into the lungs. Cells in the airways might make more mucus than usual which can further narrow the airways.

Management of Asthma

Expert Panel Report 3 (EPR-3) Guidelines for the Diagnosis and Management of Asthma The 2007 EPR-3 Guidelines were developed by an expert panel commissioned by the National Asthma Education and Prevention Program (NAEPP), coordinated by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH). The expert panel organized the literature review and final guidelines report around four essential components of asthma care: assessment and monitoring patient education control of factors contributing to asthma severity pharmacologic treatment https://www.nhlbi.nih.gov/files/docs/guidelines/asthsumm.pdf

Best Practices to Treat & Manage Asthma Assess asthma severity at the first visit to determine initial treatment. Use a written asthma action plan to guide patient self- management. Use inhaled corticosteroids to control asthma. Reduce exposure to allergens and irritants that worsen the patient’s asthma. Provide patient self-management education at multiple points of care. To reinforce the essential aspects of effective asthma management, the EPR-3’s companion Guidelines Implementation Panel (GIP) Report: Partners Putting Guidelines into Action prioritized six clinical practice recommendations that could reduce both the individual and societal burden of asthma if implemented broadly. You can make a difference now by weaving these Guidelines Implementation Panel strategies into your own practice. https://www.nhlbi.nih.gov/files/docs/guidelines/asthsumm.pdf

Assess Asthma Severity The 2007 EPR-3 Guidelines use the following severity of asthma classification, with features of asthma severity divided into three charts to reflect classification in different age groups (0-4, 5-11, and 12 and older). Intermittent Mild persistent Moderate persistent Severe persistent cough, wheezing, chest tightness, or difficulty breathing less than twice a week cough, wheezing, chest tightness, or difficulty breathing 3-6 times a week cough, wheezing, chest tightness, or difficulty breathing daily cough, wheezing, chest tightness, or difficulty breathing that are continual flare-ups are brief, but intensity may vary flare-ups may affect activity level   nighttime symptoms less than twice a month nighttime symptoms 3-4 times a month nighttime symptoms 5 or more times a month frequent nighttime symptoms no symptoms between flare-ups lung function test FEV1 is 80% or more above normal values lung function test FEV1 is above 60% but below 80% of normal values lung function test FEV1 is 60% or less of normal values peak flow has less than 20% variability am-to-am or am-to-pm, day-to-day peak flow has less than 20-30% variability peak flow has more than 30% variability Classification includes: intermittent asthma, mild persistent asthma, moderate persistent asthma, and severe persistent asthma.

Asthma Control Test The Asthma Control Test™ provides a numerical score to help the person with asthma speak with their provider to determine if their asthma symptoms are well controlled. If their score is 19 or less, then their asthma symptoms may not be as well controlled as they could be. This is a quick and effective way that Community Health Workers can assess asthma severity and refer to a physician if necessary.

Asthma Action Plan Individualized plan Team-based care Self, physician, family members, caregivers, school staff, coaches, etc. Developed and REVISED All individuals with asthma should have an asthma action plan. The asthma action plan is a written, individualized plan that shows the person’s daily treatment, such as what kind of medicines to take and when to take them. The individual will work with their doctor to develop an asthma action plan tailored to their asthma management. People that are involved in the care of the person with asthma should be made aware of the asthma action plan. This includes family members, school and childcare center workers, coaches, etc. Asthma action plans are an essential part of care provided to patients with asthma as they work together with their provider to identify triggers and symptoms to decrease the overall burden for the patient. These plans should be reviewed and refined at every follow-up visit. At the very least, on an annual basis.

Inhalers & Spacers Controller Long-term – taken daily over a period of time Reduces inflammation Relaxes airway muscles Improves symptoms and lung function Rescue/ Relief Short-acting – provides short- acting, quick relief in response to asthma attack Opens airways quickly Medications for asthma are prescribed for two different purposes: to stop an immediate flare-up, and to control inflammation and reduce lung damage over the long-term. Long-term control medications are usually taken daily to maintain inflammation and prevent flare-ups. While rescue medications, also known as bronchodilators, help open the airways when the person experiences an asthma attack. Spacers are recommended with inhaler use. The spacer makes it easier and more efficient for the medication to reach the lungs. Spacers are recommended with inhaler use. This device is a type of chamber that attaches to the inhaler and slows the delivery of the medication. Spacers help deliver the medication directly into the lungs.

Control Exposure to Allergens & Irritants Indoor mold Pollen Air pollution Animal dander Dust mites Cockroaches Irritants Tobacco smoke Wood burning smoke Perfumes and sprays Household chemicals Strong odors Other Flu and cold virus Vacuum cleaning (use a dust mask) Sulfites in foods Cold air Certain medicines Extreme emotion (crying or laughing) Although asthma cannot be cured, most people can control asthma so that they have fewer symptoms and can live healthy, active lives. An asthma episode can happen when someone is exposed to “asthma triggers” or something to which they are sensitized. Triggers can be very different for each individual with asthma.  They may react to just one trigger or they may find that several things act as triggers. Knowing their triggers and learning how to avoid them are simple actions an individual can take to control their asthma. Some of the most common triggers are the ones you see here on the slide.

Asthma Self-Management Education Asthma self-management education is a fundamental component of asthma management guidelines. Self-management education should include the provision of information, self-monitoring, regular medical review and the provision of a written asthma action plan. SME programs have been proven to reduce symptoms of ongoing health problems and improve quality of life. As you will see in the video, American Lung Association’s Open Airways for Schools is a school-based curriculum that empowers youth 3rd – 5th grade to recognize signs of an asthma attack and advocate for their own health.

Address & Improve Asthma

CDC’s 6|18 Initiative By 6|18, the CDC is targeting six common and costly health conditions – tobacco use, high blood pressure, healthcare- associated infections, asthma, unintended pregnancies, and diabetes – and, initially, 18 proven specific interventions that formed the starting point of discussions with purchasers, payers, and providers. The number of interventions may fluctuate over time. https://www.cdc.gov/sixeighteen/index.html

CDC’s 6|18 Initiative – Control Asthma Promote evidence-based asthma medical management in accordance with the 2007 EPR-3 Guidelines. Promote strategies that improve access and adherence to asthma medications and devices. Expand access to intensive self-management education for individuals whose asthma is not well-controlled with guidelines-based medical management alone. Expand access to home visits by licensed professionals or qualified lay health workers to improve self-management education and reduce home asthma triggers for individuals whose asthma is not well- controlled with guidelines-based medical management and intensive self-management education. https://www.cdc.gov/sixeighteen/index.html

Efforts of FAP to Address & Improve Asthma Develop, manage, track, and analyze a uniform set of asthma health status indicators that are derived from a variety of sources and accommodate state and local asthma related data needs through the statewide asthma surveillance system. Engage community partners to increase community readiness to identify gaps in the delivery of asthma-related programs and services to improve Florida’s existing asthma system of care. The Florida Asthma Program coordinates statewide efforts to reduce asthma disparities and hospitalization rates as well as increase the number of people with asthma receiving self-management education. The program takes a comprehensive approach to preventing and reducing asthma disparities in Florida by following an integrated approach as set forth by the Centers for Disease Control and Prevention National Asthma Control Program. Programmatic initiatives have been developed and integrated into the three component areas: partnerships, surveillance, and interventions. The goals of the Florida Asthma Program are to: Elaborate on NICHQ https://www.nichq.org/project/florida-asthma-and-tobacco-cessation-learning-and-action-network

Efforts of FAP to Address & Improve Asthma Facilitate the statewide asthma coalition, Florida Asthma Coalition (FAC), focused on eliminating asthma disparities, improving quality of life, and reducing costs. Promote and expand quality asthma self-management education and reduce exposure to asthma triggers through school-based programs and home-visiting environmental assessment. Increase public awareness of the importance of reducing the burden of asthma and the need for supportive policies and environments. The goals of the Florida Asthma Program are to: Elaborate on FAC ASME – Open Airways & Kickin’ Asthma Mention All Recognitions (School, Childcare, Hospital, and Provider) http://floridaasthmacoalition.com/

Comments/Questions

Contact Information: Shaláwa Triggs Asthma Program Manager Florida Department of Health 4052 Bald Cypress Way, Bin A-18 Tallahassee, FL 32399-1744 Phone: 850-901-6659 Email: shalawa.triggs@flhealth.gov