Charlotte Long is all smiles as she watches her grandson run and play at Cincinnati’s beautiful new Washington Park. “It’s wonderful to see him,” she says. “Last summer was really bad. He was sick a lot and couldn’t play outside.”
Antonio Long, 4, suffers from asthma. Exercise is one of the triggers that starts him coughing and wheezing.
Before his asthma was under good control, breathing problems brought Antonio to the emergency department (ED) several times, and his grandmother, who is his guardian, missed work to take care of him when he was sick.
Antonio and Charlotte enjoyed a happier summer this year, thanks to an intensive effort at Cincinnati Children’s to improve care for children with asthma.
Targeting Community Health Issues
Cincinnati Children’s strategic plan targets four major community health issues. Asthma is one of those priorities.
Asthma is the most common chronic disease of childhood and one of the top reasons children are admitted to the hospital. In Hamilton County, Ohio, one in six children has been diagnosed with asthma. The figure increases significantly for children who live below the poverty line.
Our goal is to help patients improve control of their asthma to prevent ED visits and hospitalizations.
The work is being accomplished through a large-scale collaboration of primary care doctors and pulmonary disease specialists, asthma care coordinators and home health care nurses, inpatient and outpatient services, hospital staff and community partners.
Knowledge and Confidence
For Antonio, the path to a better quality of life began last January, during a routine visit to the Pediatric Primary Care Center (PPCC) at Cincinnati Children’s.
Because Antonio required emergency care several times in 2011, Charlotte was offered the opportunity to meet with Lauren Poling, one of two asthma care coordinators in the PPCC.
Says Charlotte, “I’m so glad I took advantage of the opportunity.”
Having a care coordinator means that Charlotte now has a teacher and an advocate to help reduce barriers to care. Charlotte counts on her if she has questions or concerns.
“I feel comfortable calling Lauren when I’m unsure what to do,” she says, recalling one hot, smoggy day when she called to confirm when to give Antonio his medicine and how much to give. Poling was able to review the asthma care plan developed by Antonio’s provider and give her guidance.
Poling also referred Charlotte to another service that made a difference: the Asthma Home Health Pathway. Since 2010, Cincinnati Children’s home health nurses have visited over 500 families to provide asthma care teaching in the home.
Cheryl Patterson, RN, visited Charlotte and Antonio six times over six months to reinforce the education Charlotte received in the hospital.
She helped Charlotte identify things in the environment that can trigger Antonio’s asthma. She taught her to look for early signs of an asthma episode, so she can give Antonio medicine to stop the attack from getting worse. She reviewed the difference between controller medicine, which is given daily to reduce inflammation and prevent flare-ups, and rescue medicine, which is given as a fast-acting treatment for wheezing and shortness of breath.
And she coached Charlotte on how to fit the inhaler mask correctly so Antonio gets all the medicine into his lungs.
“Education is everything,” Charlotte says. “I know I’m doing it right, and Antonio was learning with me. He knows how many puffs to take.”
A Bundle of Interventions
Antonio’s asthma is under much better control, thanks to education and support that gave Charlotte the skills and confidence she needs to manage his care.
The asthma initiative also includes approaches designed to meet other challenges families face.
An Asthma Inpatient Task Force, led by hospitalist Jeffrey Simmons, MD, and Asthma Center director Carolyn Kercsmar, MD, spearheaded efforts to improve families’ access to asthma medications at home. Children who’ve had a hospital stay due to asthma now go home with a month’s supply of medicine and a copy of the child’s asthma care plan.
In another improvement on the inpatient units, respiratory therapists now conduct an asthma risk assessment, using a checklist embedded in the hospital’s electronic medical record. The assessment identifies families who would benefit from an asthma care plan, education during the hospital stay, participation in the Asthma Home Health Pathway or referral to community resources.
The same risk assessment tool is used by asthma care coordinators in our primary care clinics to assess high-risk patients and by our home health care nurses during home visits.
When conventional treatment, care coordination and education aren’t enough, the hospital’s Asthma Center offers intensive, specialized care by pulmonary disease experts.
Partners in the Community
Work to improve outcomes for children with asthma extends to collaborations with many partners in the community.
One effort is a school-based asthma initiative at Rockdale and South Avondale elementary schools, both located near our main campus in the Avondale neighborhood.
Another is a long-standing asthma initiative with 38 community-based pediatric practices that are members of Tri State Child Health Services, a physician hospital organization. Collectively these practices serve 13,000 children with asthma in Greater Cincinnati.
And as a participant in the Greater Cincinnati Beacon Collaboration, Cincinnati Children’s is working with hospitals and organizations across the community to marshal health information technology to improve asthma care. The Department of Health and Human Services launched the Beacon Community Program in 2010 with grants to 17 communities, which are models for innovation using information technology to tackle leading health problems. The Greater Cincinnati HealthBridge collaboration is focusing on asthma and diabetes.
In March, HealthBridge introduced an ED Admit Alert System that sends electronic alerts to primary care physicians when their patients with asthma or diabetes visit the emergency room in any of 21 area hospitals.
Mona Mansour, MD, heads the Beacon program for the Cincinnati Children’s primary care clinics. She notes that “having regional alerts made us aware of patients who are eligible for asthma care coordination because of visits to providers outside of the hospital. It allows us to reach out to these patients, regardless of where they go for care.”
All of these initiatives are keeping kids out of the hospital.
Dr. Mansour reports that children admitted to the hospital for asthma are now 50 percent less likely to be readmitted or to be seen in the ED within 30 days, and are 23 percent less likely to return within 90 days. For high-risk children who receive asthma care coordination in our primary care clinics, the average number of days between ED visits or hospital admission has gone from 173 to 325 days.
The numbers are impressive. But nothing is more impressive to Charlotte Long than watching Antonio run through the park.