by Sarah Stankorb
Carolyn Kercsmar, MD, directs the Asthma Center at Cincinnati Children’s.
Of the 36,000 children with asthma in Hamilton County, more than 4,700 are students in the Cincinnati Public Schools (CPS).
The number reflects the high rates of asthma common to urban populations. Most of the school district’s students are African American, who have a 60 percent higher asthma prevalence than the overall population. Many live in high-risk neighborhoods where poverty, lack of transportation to healthcare, chaotic housing, and low health literacy among parents all combine to make it hard to keep asthma under control.
These are the children who feel an alarming but all-too-familiar tightness when a smoker lights up in the apartment, who risk having an exacerbation during football practice, who go without medication when their inhaler runs out and no one at home has the time or resources to pick up a new one.
These are the children who miss too much school because of their poorly controlled asthma. So this is where Cincinnati Children’s, through its Asthma Population Health Initiative, wants to help create an “asthma-free school.” It might sound like a near-impossible dream, but this is exactly where the expertise of one of the nation’s top asthma centers is needed the most.
The mission is to test and change the system, says Carolyn Kercsmar, MD, Director of the Asthma Center at Cincinnati Children’s, to see if it is possible to create a school environment where students with asthma are “free from exacerbations.” Success would mean “students would be free from the need to miss school due to asthma. They would have good asthma control,” she says. “Our goal was to put resources in schools to make that happen.”
PILOT PROJECT TAKES OFF
Beginning in spring 2015, the asthma population health team began piloting a $300,000 asthma-free schools program at Oyler School in Price Hill and South Avondale School, both of which have well-established school-based health centers. The program includes support from Cincinnati Children’s James M. Anderson Center for Health Systems Excellence, the Luther Foundation and the Verizon Foundation.
High-risk students and those who frequently miss school due to asthma are invited into a program in which daily controller medication can be administered at school, supervised by the school nurse or health assistant. Students, school staff and parents will take part in asthma education and training, which will include public service videos produced by Cincinnati students.
An inhaler cap sensor and mobile software management program called Propeller Health will provide school nurses and primary care physicians with real-time feedback of medication adherence and symptom reporting. Cincinnati Children’s also will provide telehealth visits with asthma specialists for students who don’t have a medical home or need a specialist consult.
Making these schools “asthma-free” will mean zero asthma-related absences — except perhaps for the most severe cases who have no optimal treatment options. The program will be able to document that students’ asthma was well controlled during the school year and that they suffered no severe asthma exacerbations.
A HISTORY OF INVOLVEMENT
Asthma experts at Cincinnati Children’s are teaming with school nurses at South Avondale School to improve health education and medication adherence for students there.
Cincinnati may be the perfect place to test the feasibility of creating just such an environment, says Gregg Sabla, project manager for the Asthma Center.
As many as one in five kids in the city has asthma, and the medical center knows from experience how hard it can be to keep them connected to care. No more than half of patients keep their appointments or fill their prescriptions. Families move frequently and parents’ cell numbers change constantly, making it hard for schools and physicians to follow up.
But Cincinnati Children’s also has years of experience working with CPS.
Starting in 2007, when Kercsmar joined the medical center, the Asthma Center partnered with Mona Mansour, MD, MS, and the Division of General and Community Pediatrics to forge a partnership with local schools. The Cincinnati Children’s team works directly with school nurses to identify children with asthma and coordinate care. Interventions have included training school nurses, providing home delivery of prescription medications, developing a home health nurse educator program, even providing school nurses “read-only” access to Cincinnati Children’s medical records for their shared students to support coordination of care.
Improving asthma care in the community has been a strategic goal at Cincinnati Children’s for several years. In 2010, one goal set for the Asthma team was to reduce emergency department visits and hospitalization due to asthma by 20 percent by June 2015. They achieved that goal a year ahead of schedule.
MUCH MORE WORK AWAITS
Even though Cincinnati Children’s provides a good safety net that has improved outcomes for kids with asthma, every net has holes. Over the next few years, the Asthma Center aims to demonstrate that comprehensive, managed asthma care that leverages partnerships with schools can create a safety net so finely woven that no child slips through the gaps.
Barb Wiley-Kroner, Supervisor of the School and Adolescent Health Program for the Cincinnati Health Department, has worked closely with Cincinnati Children’s asthma program and is well aware of the challenges ahead. With every new school year, the need to educate new classes of families and patients about asthma returns.
“We’ve had families that did not really view asthma as a chronic illness to be managed,” she says. “They just lived exacerbation to exacerbation. So long as their kid didn’t flare up, they thought they were fine.”
What’s more, Wiley-Kroner notes, some students with asthma do not realize how far their symptoms are from ordinary. She recalls a student at CPS’ well-known School for Creative and Performing Arts who shrugged off the fact that she was wheezing audibly after finishing ballet class.
“She said, ‘Is this my asthma? I always breathe like this.’ Many of our students with asthma don’t realize their friends without asthma don’t struggle as much to breathe.”