Creating a Medical Home for Asthma: Improving quality of care for asthma in pediatric clinics

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Creating a Medical Home for AsthmaImproving
quality of care for asthma in pediatric clinics

• presented by
• David Evans, Ph.D.
• With funding from
• National Heart, Lung, and Blood Institute
• Centers for Disease Control and Prevention

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Overview

• Review the development and evaluation of the CMHA
  program in partnership with the New York City
  Child Health Clinics.
• Discuss the translation process carried out with
  CDC and Research Triangle Institute.
• Describe the web-based CMHA materials.

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New York Citys Child Health Clinics

• 45 clinics in low income neighborhoods.
• 90 of patients were children under age 7
• 50 were uninsured and received free care
• Provide preventive care plus treatment for minor
  illness.
• Staff had very little experience providing
  outpatient care for asthma.

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NYC DOH Building in Brooklyn
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Clinic teams include

• Pediatrician
• Public health nurse
• Public health assistant
• Receptionist
• Laboratory technician (2-3 days per week)

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Child Health Clinic Team
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Child Health Clinic Leadership

• Wanted to deliver more complete pediatric care to
  enrolled patients.
• Were aware of asthma as a community problem.
• Reviewed records and found only 2 of enrolled
  children had a diagnosis of asthma.
• Surveyed medical and nursing staff who said they
  were interested in learning to provide better
  asthma care.
• Invited us to work with them to improve asthma
  care.

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Pilot Study

• CHC and Columbia began a pilot study in 9 clinics
  in the Bronx.
• We did not do a needs assessment.
• We assumed that training in medical care and
  patient education for asthma was enough to
  produce change.
• We held two traditional CME sessions to teach
• Doctors to screen patients for asthma and provide
  medical care based on the NHLBI guidelines
• Nurses to provide family education about asthma

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Pilot Study Results

• CME increased identification of asthma patients,
  but had no impact on treatment. So we visited
  clinics, talked with staff, and found the
  following barriers to change
• Staff didnt see why CHC should treat asthma, and
  thought ED was better source of care.
• They had little understanding of continuing,
  preventive care for a chronic illness and low
  self-efficacy to treat asthma.
• Doctors thought asthma patients would take a long
  time, and thus reduce their productivity.
• All clinic staff feared a surge of walk-in
  patients would overwhelm them, turning the clinic
  into an ED.

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Pilot study results

• We also found that there was little team
  workeach person had their own job.
• Most clinics had one telephoneon the desk of the
  receptionist.
• The staff did have a strong sense of missionto
  provide preventive care services in the
  community.
• Nursing and physician supervisors were supportive
  of the initiative.

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Controlled Research Design

• Following the pilot study, we obtained a grant
  from NHLBI to test a revised training program.
• 22 clinics were matched for size, minority
  patients, and asthma patients.
• Clinics were randomly assigned to program and
  control groups, with two-year follow up.

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We revised the program to

• Develop a rationale for treating asthma
  Preventive care to meet a community need.
• Train all staff to work together to make their
  clinic a Medical Home for Asthma.
• Involve supervisors and staff in planning and
  implementing the program.
• Address organizational barriers.

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Revised training plan

• Five group sessions with all clinic staff were
  held over three months.
• An individual tutorial with each physician held
  at Columbia.
• Monthly visits to each clinic by our
  nurse-educator.
• Supervisory support for staff to adopt the new
  approach to care for asthma.

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Access to staff for training

• Clinic leaders closed clinics for half a day and
  assigned all staff to attend training.
• We worked with staff of 2-3 clinics at a time.
• With make up sessions, attendance was 100.

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Involving Supervisors

• We invited supervisors to meet for a day of
  training before the program started
• Held meeting at Tavern on the Green
• Asked for their input on organizational barriers
• Asked them to use supervisory meetings to review
  progress and support the program
• Provided interactive training on management style
  to encourage staff input.

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To build a rationale for treating asthma, in
Session 1 we presented data about

• Increasing rates of asthma in the US, NYC, and in
  minority neighborhoods.
• The need for preventive care to control asthma,
  and the inability of the ED to provide this.
• How continuing care for asthma fit the CHC
  mission of preventive care services.
• CHC leaders stated their goal of providing full
  pediatric services, including asthma care.

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To address organizational barriers and lack of
teamwork, we

• Had clinic staff interview each other to identify
  factors that would help or hinder program success
  (Session 1).
• Provides a public, anonymous consensus about key
  issues
• Then clinic teams work together to solve one of
  the problems identified (Session 2).
• Teams create plan for immediate action
• Take ownership of program

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The Interview Technique
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To deal with organizational and teamwork issues,
we also

• Showed a videotape that modeled clinic teamwork
  in helping a family accept and follow a new
  treatment plan (Session 5).
• Teams were asked to hold monthly staff meetings
  to discuss implementation of the asthma program
  in their clinic.
• We installed telephones in pediatricians
  offices.

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To address concerns about patient load, in
Session 3

• We demonstrated how the introduction of new
  asthma therapy and family education could be done
  over several planned visits.
• Showed how acute episodes could be managed while
  seeing other patients.
• CHC leaders assured physicians that asthma
  patient load would be considered in assessing
  productivity.
• CHC leaders addressed fears of patient overload
  by clarifying that staff were not obligated to
  see walk-ins.

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To develop skill and confidence to provide good
asthma care

• We explained the concept of asthma as a chronic
  illness.
• Modeled preventive care approach through
• Lecture and discussion
• Skits enacted by clinic staff
• Videotapes of investigators treating and
  educating patients
• Having clinic physicians visit our offices
• Providing written treatment plans for patients of
  different severity
• Had CHC staff practice using inhalers, spacers,
  and nebulizers, and discuss how to teach families
  to use them.

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Teaching Clinic Staff To Teach
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Data Sources for Evaluation

• CHC encounter form database recorded
• Scheduled visit vs. walk-in
• Diagnoses dealt with during visit
• Medications prescribed or dispensed
• Acute episode vs. follow up visit
• Interviews with caregivers of children with
  asthma.
• Questionnaires given to clinic staff.

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Percentage of clinic patients with asthma
P 25
Annual scheduled asthma visits
P 26
Percentage of children treated with inhaled
anti-inflammatory medicines
P 27
Percentage of families reporting education on 12
topics from MD RN
PP 28
Hospitalizations for Asthma
PNS
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Emergency Department Visits
P 30
Unscheduled Clinic Visits for Asthma
P
P 31
Summary of findings

• The program had a positive impact on
• Identification of children with asthma
• Increasing scheduled visits for asthma
• Providing appropriate therapy
• Increasing patient education
• The program also showed a shift of urgent care
  visits from ED to clinic
• No clear health benefit
• Better use of health care resources

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Conclusions about intervention

• A thorough needs assessment is essential.
• Overcome barriers to change through
• Policy changes or clarification
• Building team problem-solving capacity
• Providing needed resources
• Use learner-centered, interactive teaching
  methods to develop skills and confidence,
  including
• modeling and practice with feedback to master
  skills
• Involve organizations leaders and supervisors in
  planning, reinforcing, and sustaining the program.

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Translation and dissemination

• Several years after results were published, CDC
  awarded RTI a contract to work with us to
  translate CMHA for use by other pediatric
  clinics.
• The RTI framework for translation involves
• Modification
• Program evaluation
• Training
• Production
• Dissemination

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Translation Modification

• Assure science in program is current
• Replace research elements and language
• Add components needed for use by others
• Introduction
• Module on getting started in a new clinic
• Management plan for implementation after training
• Evaluation tools

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Translation Evaluation

• Develop an approach for local evaluation of
  implemented program
• Include process, impact, and outcome evaluation
• Provide an evaluation plan
• Design considerations
• Levels of measurement
• Plan implementation
• Sample evaluation instruments

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Translation Training

• Identify competencies needed for the
  intervention team
• Provide a training curriculum and/or
  implementation guide

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Translation Production

• Develop user-friendly materials appropriate for
  target audience
• Use effective design and layout principles for
  different formats (i.e., hard copy, web-based)

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Translation Dissemination

• Identify a homethe New York City Department of
  Health Mental Hygiene
• Determine a distribution and marketing plan
• Determine oversight (i.e., maintenance)
  responsibility

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Features of the CMHA Web Site

• Accessibility materials downloadable in two
  additional formats pdf and MS Word
• Resources helpful links provided to obtain
  additional information related to asthma
• Section 508 compliance web site usable and
  available to people with disabilities

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Benefits of CMHA for clinic staff

• Working together to improve quality of care for
  asthma can
• Improve patient satisfaction with care
• Improve patient health outcomes
• Improve clinic staff satisfaction with their work
• Create a sense of teamwork among clinic staff
  they can apply to other problems

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Web Site Access Resources

• www.nyc.gov/html/doh/html/cmha/index.html
• You can use this email address for follow up
  questions about the site healthcmha_at_health.nyc.go
  v
• Study findings Evans D et al, Pediatrics
  199799157-164.

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Acknowledgments

• Winston Liao, RTI International
• Michelle Hsiang, RTI International
• Leslie Boss, Centers for Disease Control and
  Prevention
• Andrew Goodman, Lorna Davis, Carmen Ramos-Bonoan,
  New York City Department of Health and Mental
  Hygiene
• Monique C.B. Winslow, Global Health Information
  Systems
• Marcia Pinkett-Heller, New Jersey City University
• Robert Mellins, Columbia University College of
  Physicians and Surgeons
• Sandra Wiesemann, Medical and Health Research
  Association of New York City, Inc.