Chapter Quality Network (CQN) Asthma Pilot Project Team Progress Presentation State Name: Ohio Practice: Toledo Children Primary Care Team Members:

Toledo Children Primary Care

Progress Summary Since Learning Session 1 Improved engagement of QI team – providers are meeting monthly to discuss use of NHLB guidelines for care of asthma patients in our office. Staff are meeting frequently to discuss best processes for improving efficiency of providing asthma care. QI data turned in monthly. Team attending all required meetings and phone conferences. Improving Follow up - Developing system to identify asthma patients by color labeling charts. Reviewing ideas for use of registry for Asthma patients. Scheduling follow up appointments at asthma visits, calling for follow up appointments after ER visits. Increasing use of Planned care approach – developing and implementing improved workflow to support use of protocols with all providers, developed new asthma visit note to use at Asthma visits. Trained staff on correct use of Spirometry testing. Completing spirometry testing on patients per provider order. Approach to Employing Protocols – Standardizing processes for each provider and staff to best implement use of evidence-based protocols with all patients. Providing Asthma Action Plan to all patients at asthma visit. Self management support – Evaluating educational materials that help patients and family learn self management of disease process. IE: written material, asthma education per individual patient or group. Phone education vs. in-person education.

Asthma Action Plan

Follow - up

Spirometry

Antonio 17 yr T’onna 12 yr

IQmark TM Digital Spirometer

Spirometry ? Low FEV1 is associated with increase risk for severe exacerbations. Regular monitoring of pulmonary function is particularly important for asthma patients who do not perceive their symptoms until airflow obstruction is severe. There is no readily available method of detecting the “poor perceivers.” The literature reports that patients who had a near-fatal asthma exacerbation, as well as older patients, are more likely to have poor perception of airflow obstruction. Two large, retrospective cohort studies have shown that a reduction in FEV1 at an annual visit is associated with increases in the risk of an attack of wheezing and shortness of breath over the next 12 mo.

Spirometry

PDSA Cycles PDSA Title:  Plan: Perform Spirometry testing in office  Do: Train nurses to accurately complete testing on appropriate asthmatic patients  Study: Validate results of Spirometry testing for accurate results on appropriate asthmatic patients  Act: Increase number of accurate tests on appropriate asthmatic patients

TEST 1 What: Perform Spirometry test Who (population): Train nursing staff Who (executes):Resp therapist: John Where: Office When: October 2009 PD SA TEST 2 What: Perform Spirometry test Who (population): 1 patient/week Who (executes):1 trained nurse Where: Office When:Oct PD SA TEST 3 What: Perform Spirometry test Who (population): 2-3 pts. Per week Who (executes): 1 trained nurse Where: Office When:Nov PD SA TEST 4 What: Perform Spirometry test Who (population): 5 pt. per week Who (executes): All trained nurses Where: Office When:Dec PD SA TEST 1 What: Validate accurate results Who (population): 5 – 10 pts Who (executes): All trained nurses Where: Office When: Jan 2010 PD SA TEST 2 What Validate results Spirometry vs Formal PFT Who (population): 1-2 pts. Who (executes): All trained nurses Where: Office When:Feb 2010 PD SA TEST 1 What: Spirometry testing Who (population): 1 patient Who (executes): Participating providers Where:Office When:March 2010 PD SA TEST 2 What: Spirometry testing Who (population): 2-5 pts/week Who (executes): All participating providers Where: office When: April 2010 PD SA TEST 3 What: Spirometry testing Who (population10 patients/week Who (executes): all trained nurses Where: Office When: May 2010 PD SA TEST 4 What: Spirometry testing Who (population): All patients Who (executes): All trained nurses Where:Office When: June 2010 PD SA Spirometry testing Monitering results Spirometry Expand Use of Spirometry testing PDSA Ramps PD SA TEST 3 What: Validate results between trained nurses Who (population): 3 pateints Who All Providers Where: Ofice When: June 2010

Scheduler identifies patient with asthma when setting up chart. CQN data collection form is put in these charts. Asthma education material put in these charts including Asthma Action Plan (Each provider work flow different, requiring different method for each of them) If in active flu season and vaccine is due, administer flu shot. If between seasons, annual flu shot is recommended CQN encounter forms readily accessible in each POD when asthma pt. indentified after chart set up Physician/CPNP/RN/LPN gives/reviews asthma action plan. Gives and reviews asthma educational materials. Offers in home asthma education. Reviews patient encounter form for completeness ( Evaluating multiple methods of providing education to lead to best self management) Nurse/CRA sends referral to Caring Service Home Health Care if accepted by family or available group asthma education at hospital During the visit the Physician/CPNP reviews pt. questionnaire and completes provider questionnaire (difficult to devote time to complete these forms) Physician/CPN/ discusses asthma control Office Visit - Prework During Office Visit Post Visit Activities Physician/CPNP Completes all forms and gives to administrative team member to enter data into equipp. (difficult to devote time to complete these forms) Physician/CPNP orders spirometry if appropriate Toledo Children's Primary Care: Clinical Assessment Process Map – Paper Chart System Nurse completes spirometery testing Patient is ready to be seen by provider Working on Creating Asthma recall registry system Nurse/CRA who rooms patient gives parent patient encounter form and helps them complete form if needed. Administrative team member returns incomplete forms to provider/CPNP DR. or CPNP gives patient encounter form to complete if they feel appropriate for that days visit.

CQN Encounter Form

Asthma Care Encounter Form for documentation at visit

Key Learning  Change is difficult. It is easier to implement small changes.  Obtaining data helps measure outcome.  Education, education, education.  Collaboration with community health care resource is very important.

Barriers and Successes 1. Time. 2. Absence of EMR. 3. Variations in care. 1.Quality of care. 2. Increased Asthma education to staff ( protocols for medications refills, f/u visits) 3- Improved teaching to future health care providers. 4- Guidelines and protocols improves efficiency and staff satisfaction, and reduces unnecessary variations of care. 5- Spirometry

Future Plans EMR/RegistryEMR/Registry Continue PDSA’s for efficient use of asthma encounter forms Continue Team meetings providers and staff Continue to evaluate methods of patient and family education to help families improve self management of Asthma.