Asthma Care Process Model Karmella Koopmeiners

7/31/2019 Asthma Care Process Model Karmella Koopmeiners

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ASTHMA CARE PROCESSMODEL AND EDUCATION

DOCUMENTATIONKarmella Koopmeiners RN MS FNP, Nurse Specialist

Primary Children’s Medical Center (PCMC) and

Intermountain Healthcare

100 North Mario Capecchi Drive

Salt Lake City, Utah 84113

e-mail: [email protected]

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mailto:karmella.koopmeiners@

mailto:karmella.koopmeiners@



Mission Statement

To Provide Excellent Asthma Care For ChildrenThrough Improved Documentation of

Education and the Revised CPMPrimary Children’s Medical Center (PCMC) is a 289-bed teaching

hospital providing 80% of inpatient services for children. US Newsand World Report recently ranked it as one of the nation’s best

children’s hospitals, recognizing them in 7/10 pediatric

subspecialties.

Intermountain Healthcare (IH)

Intermountain Healthcare has 22 facilities, 5 of the 9 rural facilities arecertified by Medicare as Critical Access Hospitals (4/Utah,1/Idaho).

These facilities recognize their stewardship in the community and

are committed to sharing information and strive to reduce costs

to consumers of healthcare while maintaining the quality of

healthcare services

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Vision Statements

• The asthma team is a multidisciplinary team of healthcare professionals committed to providingextraordinary care for pediatric patients. This isaccomplished through improved patient and staffeducation, communication, clinical excellence and

evidence-based practice using NHLBI and NAEPPguidelines.

• We support a patient/family centered approach;

including self-monitoring tools and participation inasthma care. We promote a collaborative effort acrossthe continuum of care by partnering with primary carefor a more proactive, preventative approach toimprove the utilization of resources measured by

patient outcomes.

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Incidence- 23 million-9.4% of children, 7.3% of adults Prevalence-only chronic illness-across the age spectrum

Impact-disproportionately low-income, American Indian

Best Practices –NAEPP Guideline #3 patient education

Costs- U.S. (2007) Total-19.7 billion

25% or 5 billion preventable by managing symptoms

Direct costs-(2010) 1,500 hospital D/C @ $16.2 million,(2009)-7,259 ED visits-$21.9 million =

$7.3 million treat-release,$14.7 million treat-admit visits

Indirect cost- absenteeism, presenteeism at work/school

Return On Investment(ROI) = dollars saved andexpenses avoided/ dollars invested

Source: Utah Department of Health (UDOH)

Background Information



PCMC Asthma Team

Clinical Nurse Specialists (Advanced Practice Nurses)

Karmella Koopmeiners, Kate Thompson

Data Team -Tanya Stout, Rebecca Baggaley

Educators-Rebecca Bawden RN, Brandon Andersen RT

Physicians-Bern Fassl-Physician and Project Leader, BryanStone, Flory Nkoy-Research Team Leader

Research Team

Sarah Halbern, Eun Hea Kim, Allison Wilcox RN

Respiratory Clinical Expanded Roles (RNs)Anna Pate CMU, Alison Kohutek IMSU, John Mohr RTU

Riverton Care Unit

Michelle Hofmann, Kristina McKinley, Kim Young RN

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Asthma Team Roles and ResponsibilitiesPROVIDER

Pt/family education and

documentation of the

revised CPM is complete

• Act as a resource to

staff for pt/ family

education and CPM

guidelines

• Reviews pediatric

questionnaire and

completes themedication

reconciliation process

• Completes admission

orders including

chronic control table

• Using the revised CPM

coordinates the plan

of care (POC) with theteam

• Completes discharge

orders and discharge

instructions (DOADI)

with modification in

the home

management plan of

care (HMPC)

REGISTERED NURSE

Coordinates , provides and

documents education and

revised CPM documentation

• Provides education to pt

/family based on needs

assessment and reinforces

medications and skills

based on observations

• Documents education

provided and pt/familyresponse to education

• Reviews pediatric

questionnaire with the pt/

family including

medication reconciliation

and chronic control table

• Ensure medication

reconciliation process isdocumented and asthma

admit orders complete

• Recommends step-up

therapy (change in home

management plan)

• Reviews discharge teaching

instructions (DOADI) with

the pt/family

RESPIRATORY THEARIPST

Provides, documents

education , assists with CPMcompletion

• Provides individual

instruction on equipment

(i.e., spacer, MDI, peak

flow, nebulizer) and other

needs unique to the

patient /family

• Reviews patient/family

technique and evaluates

the return demonstration

of skills

• Reviews needs assessment

and completes

documentation on the

teaching outline

• Reinforces the concepts

taught by the team

• Assists pt/family with

pediatric questionnaire• Communicates and

collaborates with the team

about educational needs

of the patient and revised

CPM implementation

• Recommends changes in

the home management

plan of care (HMPC)

CLINICAL EXPANDED

ROLE/EDUCATORS

Provide clinic expertise

in asthma

• Develops and revises

education content

and documents (job

aides , handouts,

schedules etc.)

• implements,

evaluates revisedCPM and provides

unit staff education

• Conducts audits of

documentation of

education, revised

CPM and provides

feedback to the staff

and teams• Act as a resource,

consultant and liaison

with providers and

teams for education

and revised CPM

development and

evaluation

CLINICAL NURSE

SPECIALIST

Advanced Practice Nurse

leaders in asthma program

development (education

and CPM)

• Develops CPM

documents (tools,

algorithms, scenarios)

and develops staff

education• Resource, consultant,

and mentor to

multidisciplinary staff

• Recommends content

for pt/family education

• Facilitator and Nursing

Leader for PCMC team

• Responsible for asthmaquality improvement

programs, EBP, research

and program

development across the

continuum of care

• Evaluates asthma data

(process and outcome)

for patients and teams

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Step-Up Therapy, MedicationReconciliation, Chronic Control Table

For Hospital Use Only

Review answers and determine the following items for this patient:

Age: __________________

Current step for asthma management: ___________

Takes controller 4 or more times a week? YES NO

Takes controller 3 or less times a week? YES NO

Does not take a controller

Degree of chronic control is:

** well controlled

** not well controlled

** poorly controlled

Recommendation for change in home management plan? ________________________________________________________________________

What Medication (s) do you or your child take to control your asthma?

MEDICATION

NAME

DOSE How many TIMES PER DAY do

you take this medication?

How many puffs/ nebs do you take per

treatment? If you are taking “pills”, how

many pills do you take each time?

On average, how many times per week do you take this

medication?

0 1 2 3 4 5 Other 1 2 3 4 5 Other________ 1 2 3 4 5 6 7 As Needed

Other_______


Other_______


Other_______


Other_______


Other_______

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How does your asthma influence your life?1. How often do you or your child have one of the following

problems: cough, wheezing, feeling short of breath, chest

tightness

Don’t

KnowTwice a week or less

More than

Twice a weekThroughout the day

2. How often do you or your child wake up from sleep with

breathing difficulties or cough? Don’t

Know

Less than or equal to

once a month

More than once a

monthMore than once a week

3. What is your or your child’s peak flow level usually? (if

recommended by your doctor) Don’t

Know

80% - 100% personal

best (green)

50% - 80% personal

best (yellow)

Less than 50% of

personal best (red)

4. How often does asthma limit you or your child’s daily

activities: playing, running, exercising, or missing school /

work?

Don’t

Know

Never Some limitation Frequent limitation

5. How often do you or your child use a quick relief (rescue)

medication (for example – albuterol)? Don’t

KnowTwice a week or less

More than

Twice a weekSeveral times a day

6. In the last year, how often did you or your child’s asthma get

worse and require oral steroids, a clinic visit, or an ED visit?Don’t

Know0 – 1 time 2 – 3 times Greater than 3 times



1. Admission Orders (paper)

2. Review Questionnaire-a. Med Rec/b. Chronic Control (paper)

c. Recommend Step-Up Therapy (paper)

3. Needs Assessment/Teaching Outline (paper)/ Tandem (EMR)

Watch Asthma DVD/TV (passive) Review Flipchart (interactive)

Consult Respiratory Therapy for skills/special needs

Return Demonstration of Skills/Medication Teaching

Discharge Teaching-DOADI/Help2 (EMR) copy and sign (paper)

Process of Education/CPM Documentation (EMR vs. Paper)



Fishbone-Documentation Problems

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Define role of RT/ nurses

in the educational process

Define role of RT/ nurses

in the educational process



Prioritization of Leverage Points

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Specific Aim StatementFrom January 2011 - March of 2012, sustaining the

board goals and improvement in documentation from

71%-85% (stretch) will occur with medication teaching:

Sustaining the 2011 Board Goal- 81%• Teaching of Triggers- 89% (paper)

• Medications difference between controllers/ relievers,equipment return demonstration-71% (paper)• Asthma Action Plan- 91% (electronic –DOADI)

2012 Board Goal- 50%

Asthma controlmedication reconciliation process-66% (paper)chronic control symptoms-67% (paper)order appropriate controllers-0% (electronic-DOADI)



Baseline Data 1/1-12/2011

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0%

20%

40%

60%

80%

100%% Asthma Patients-Action Plan



Teaching Meds-2011/2012 YTD13

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2011.012011.022011.032011.042011.052011.062011.072011.082011.092011.102011.112011.122012.012012.022012.03

% of Patients Med Teaching

Average % with Teaching Medications LCL UCL



Solutions to Problems

• Role/Responsibility delineation document created (slide 6)

• Education channel, back-up DVDs in toolboxes

• Staff education on the CPM (slide 7), created patient

scenarios for chronic control and step up-therapy usingtools such as the Quick-Guide and Primary Care CPM

• DOADI revised to include new components and reduceformat from 9 to 2 pages

• Team completed a survey to prioritize problems (slide 10)• Reinforced use of the Teaching Outline

• Assisted units with the transition of documentation onpaper forms to electronic medical records

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Specific Aim StatementFrom January 2011 - March of 2012, sustaining the

board goals and improvement in documentation from

71%-85% (stretch) will occur with medication teaching:

Sustaining the 2011 Board Goal- 81%• Teaching of Triggers-89%

• Medications difference between controllers/ relievers,equipment return demonstration-71% (paper)• Asthma Action Plan- 91% (electronic –DOADI)

2012 Board Goal- 50%

Asthma controlmedication reconciliation process-66% (paper)chronic control symptoms-67% (paper)order appropriate controllers-0% (electronic-DOADI)

87% Overall

69% Overall

96%

96%

73%

98%36%

85%



2012 Goal -YTD

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Stretch ≥90% (RV) , ≥80% (System, MK, PC, UV), ≥75% (LG, AF, DX)

Target ≥85% (RV), ≥75% (System, MK, PC, UV) , ≥70% (LG, AF, DX)

Yellow Not Red, and Not Target or Stretch

Red <80% (RV), <71% (PC), <70% (System, MK, UV), <60% (LG, AF, DX



2003-2011 6 Month Readmission RateChanges

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Q 1

2 0 0 3

Q 2

Q 3

Q 4

Q 1

2 0 0 4

Q 2

Q 3

Q 4

Q 1

2 0 0 5

Q 2

Q 3

Q 4

Q 1

2 0 0 6

Q 2

Q 3

Q 4

Q 1

2 0 0 7

Q 2

Q 3

Q 4

Q 1

2 0 0 8

Q 2

Q 3

Q 4

Q 1

2 0 0 9

Q 2

Q 3

Q 4

Q 1

2 0 1 0

Q 2

Q 3

Q 4

Q 1

2 0 1 1

Q 2

Q 3

Q 4

Q 1

2 0 1 2

0.00

0.05

0.10

0.15

0.20

0.25

0.30

0.35

0.40

0.45

0.50

0.55

0.60

A v e r a g e

Summary

Apr 16, 2012 10:57:48

Quarterly Readmissions w/in 6 months of Discharge: PCMC

77 67 41 55 60 45 48 53 73 60 46 77 60 49 63 80 80 62 39 75 102 83 68 62 124128113 82 127 87 72 68 119100 79 73 119n



Asthma Readmission Rate Reduction at PrimaryChildren’s and Nationally

0%

5%

10%

15%

20%

25%

30%

35%

40%

P e r c e n t a g e o f I n p a t i e n t s w h o R e

t u r n e d W i t h i n 1 8 0

D a y s

2010 Asthma Inpatient Encounter (APR-DRG 141)Returns to Hospital within 180 Days – Same APR-

DRG

% Inpatient Returns % ED Returns

Source: Child Health Corporation of

America’s Pediatric Health Information System database

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Future Plans• Audit electronic

documentation

• Make PCMC DVD

• Develop continuousalbuterol protocol

• Develop an asthma

scorecard

• Implement web-based

self-monitoring tool andCare Process Modelacross the system (ED,Insta/Primary Care)

• Partnerships with UDOHand EPA (NAEPP #4) toimpact triggers/homeenvironment

• Business Plan for Returnon Investment (ROI)-direct and indirectmeasures

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Thank-you!20

Asthma Care Process Model Karmella Koopmeiners

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