1. Chapter Quality Network (CQN) Asthma Pilot Project Team Progress Presentation State Name: Alabama Practice Name: Pediatric Associates of Auburn Team Members: Wes Stubblefield, M.D., F.A.A.P., Dianne Carlton, Erica Bentley, L.P.N.

3. Progress Summary Since Learning Session 1 1. Beginning with LS1, implemented study on a limited basis with one provider and expanded to all asthmatic office patients with all providers. 2. Developed reliable process for identifying asthmatic patients and distributing encounter forms in office flow. 3. Increased identification of asthmatic patients through use of encounter form and spirometry per guidelines. 4. Increased evidence-based guideline treatment of asthmatic patients by using NLHBI stepwise approach to therapy. 5. Improved outcomes with increased flu shot recommendations for all asthmatic patients and regular use of spirometry in follow up. 6. Improved follow up reliability with identification and missed visit calls.

4. % of Patients with AAP

5. Spirometry within 1-2 years

6. F/U appt recommended

7. Optimal Asthma Care

8. PDSA Cycle – Follow up PDSA Title:  Plan: Recommend follow up to all study patients per guidelines, expanded to all asthma patients with all providers.  Do: Asthma patient tagged in EHR. Each visit, symptoms/medications reviewed by L.P.N. and M.D. and follow up recommended as appropriate or per guidelines.  Study: Noted that some patients were not keeping scheduled appointments for follow up. Implemented “no show” strategy, front office staff to notify M.D. and L.P.N. if patient missed appointment. L.P.N. contacted family personally to stress the importance of keeping scheduled appointments and reschedule. Noted improvement with keeping appointments as expected.  Act: At follow up visit, asthma action plan reviewed, follow up spirometry scheduled or performed, if indicated. Asthma action plan modified as needed.

9. TEST 1 What:: Identifiy asthmatic patients for study Who (population): Limited population Who (executes): MD/Nurse Where: Office flow, MD work area When: Immediately PD SA TEST 2 What:: Distribute AAP to all identified pts Who (population): Alll identified pts Who (executes): Nursing staff Where: Triage Area When: 15 days PD SA TEST 3 What:: AAP to all identified pts Who (population): All identified pts Who (executes): MD Where: Exam room When: 30 days PD SA TEST 4 What:: AAP to all asthmatic patients Who (population): all asthmatic pts Who (executes): Nurse hands out form, MD completes Where: Triage/Exam Room When: 45 days PD SA TEST 1 What:: Identify pts needing current spirometry Who (population): Limited population Who (executes): MD review of chart Where: Exam room, EHR When: Immediately PD SA TEST 2 What:: Provide spirometry per guidelines (current or new diagnosis only) Who (population): Limited population Who (executes): MD orders, nurse performs Where: Exam room or Lab When: 15 days PD SA TEST 3 What:: Spirometry to asthmatics per guidelines Who (population): All asthmatic patients Who (executes): MD orders, nurse peforms Where: Exam room or Lab When:30 days PD SA TEST 4 What:: Spirometry f/u per guidelines in addition to initial spirometry for diagnosis Who (population): All asthmatics Who (executes): MD orders, nurse performs Where: Exam room or Lab When: 45 days PD SA TEST 1 What:: Recommended f/u to study patients per guidelines Who (population): Study patients only Who (executes): MD Where: Exam room When: Immediately PD SA TEST 2 What:: Expanding follow up to call asthmatic patients Who (population): all asthmatic patients Who (executes): MD Where: Exam room When: 15 days PD SA TEST 3 What:: EHR tagging of asthmatic patients to follow up Who (population): all asthmatic patients Who (executes): Front Desk Where: Front Desk When: 45 days PD SA TEST 4 What:: Call back for missed appts Who (population): All identified pts Who (executes): MD orders through EHR Front desk performs Where: Exam room, front desk When: 60 days PD SA Asthma Action Plan (AAP)SpirometryFollow up PDSA Ramps

10. Asthma patients identified by EHR FLASHER PATIENT CHECKS IN AT FRONT DESK – LPN REVIEWS PATIENT HISTORY - I.E., EXPOSURE TO CIGARETTE SMOKE, FLU SHOT STATUS, MEDICATION LIST LPN GIVES ASTHMA ENCOUNTER FORM TO PARENT ANY NEW OR UNIDENTIFIED PATIENTS ARE IDENTIFIED DURING TRIAGE BY LPN AND GIVEN ASTHMA ENCOUNTER FORM M.D. REVIEWS ENCOUNTER FORM – COMPLETES ENCOUNTER FORM IN EHR REVIEWS HISTORY OF PROGRESS OR FAILURES WITH CURRENT TREATMENT. M.D. PROVIDES EDUCATION & ASSESSES NEED FOR SPIROMETRY AND/OR ALTERNATE MEDICATION PLAN LPN PERFORMS SPIROMETRY IF ORDERED M.D. REVIEWS SPIROMETRY RESULTS – ADJUSTS MEDS AS NEEDED – ADVISES F/U AS PER RESULTS Office Visit - Prework During Office Visit Post Visit Activities PEDIATRIC ASSOCIATES OF AUBURN FRONT DESK CHECKS FOR F/U INSTRUCTIONS AT CHECKOUT FOR ALL ASTHMA PATIENTS – F/U SCHEDULED AS INDICATED BY M.D. NEW/UNIDENTIFIED ASTHMA PATIENTS CHARTS ARE FLAGGED IN EHR M.D. ENTERS DATA IN TO EQUIPP – SENDS FORM TO FRONT OFFICE FOR SCAN IN TO CHART ENCOUNTER FORMS PLACED ON M.D.’S DESK FRONT OFFICE NOTIFIES LPN AND M.D OF ANY ASTHMA PATIENT MISSED APPTS M.D. REVIEWS PATIENT CHART – LPN CONTACTS PARENTS TO RESCHEDULE FOLLOW UP APPT ASTHMA PATIENTS INDENTIFIED BY EHR FLASHER PATIENT CHECKS IN AT FRONT DESK – LPN REVIEWS PATIENT HISTORY - I.E., EXPOSURE TO CIGARETTE SMOKE, FLU SHOT STATUS, MEDICATION LIST

11. CQN Encounter Form

12. Key Learnings  Obviously, although we felt we performed quality asthma care, our experience through this project tells us otherwise.  However, with a little work and some direction through the collaborative, we were able to increase our optimal asthma care into the goal range.  Our data have not shown significant increases in our well controlled patients and admission rates yet, but we plan to see that increase over the next few months.

13. Barriers and Successes Barriers: –Being a small office, implementing any change is usually quick, but requires increased time for the staff. We have very little extra staff to handle increased workload (3 non-clinical staff including office manager). Successes: –We feel that we have integrated this project into our workflow such that, even when busy, we are able to complete our forms. –We were also able to integrate the CQN form into EHR.

14. Future Plans Identify all prior asthmatic patients through practice management software and ICD-9 review. Implement registry through RMD. More formalized asthma education, e.g. spacer teaching, MDI teaching, DPI teaching Formalized staff training More integration of project with EHR (starting with encounter form – Thanks Partners in Peds!!)