1

Respiratory Care

Certificate Program

TOOL KIT

This education program is a product/publication of the National Community Pharmacists Association (NCPA).

Copyright © 2007. All rights reserved. Any reproduction, photocopying, storage or transmission by magnetic or electronic means without the expressed written consent of NCPA and the payment of

appropriate fees is strictly prohibited by law.

2

ASTHMA MEDICAL HISTORY

1. At what age were you diagnosed with asthma ? _________ years old

2. Has your asthma gotten better or worse over the last year ? ______________

3. How many times in the last year have you gone to the emergency room or an urgent care facility for

treatment of your asthma ? _____________ times

4. How many days per month do you miss of work or school due to your asthma ? _______days

5. What are your most common symptoms during an asthma flare-up ?

! cough ! wheezing ! shortness of breath ! chest tightness ! sputum production

6. Does your asthma limit your daily activities ? ! Yes ! No

7. Does your asthma limit you from participating in sports or strenuous activities ? ! Yes ! No

8. How often does your asthma flare-up ?

! Less than once a week ! 1-2 times/week ! 3-5 times/week ! daily

9. How many times a week do you wake up from sleep with asthma symptoms ?

! Never ! 1-2 times/week ! 3-5 times/week ! daily

10. Is there a time of year that your asthma symptoms worsen ?

! Winter ! Spring ! Fall ! Summer

11. Have you ever been tested for allergies ? ! Yes ! No

12. How often are you prescribed oral corticosteroids to control your asthma ?

13. What do you do when your asthma symptoms start to worsen ?

14. Does the cost of asthma medication impede you from taking your medications as prescribed ? ! Yes ! No

15. Do you use a peak flow meter to monitor your asthma ? ! Yes ! No

16. Has your doctor instructed you how to treat your asthma if it worsens ? ! Yes ! No

17. Do you have a written asthma action plan ? ! Yes ! No

3

ASTHMA CONSULTATION FORM

PATIENT NAME: DATE:

Subjective:

CURRENT MEDICATION USAGE

(medication name, strength, and patient use)

How is your asthma/breathing today ?

New complaints ?

Any medication problems or changes ?

SYMPTOMS ! FREQUENCY (occurrences/week)

Coughing

Wheezing

Chest tightness

Shortness of breath

Nocturnal symptoms

Symptoms during exercise

Missed school or work

Physician or hospital visits

PRN "-agonist use

DEVICE ! USAGE

Metered Dose Inhaler

Spacer

Nebulizer

Peak Flow Meter

Peak Flow Diary

Objective: Peak Flow ________l/min Respiration _____bpm Pulse:_____bpm

Assessment:

Plan:

Follow-up: Date ___________ Time: ___________

PHARMACIST: SIGNATURE:

4

TRIGGER EVALUATION FORM

TRIGGERS PREVENTIVE MEASURES

! Household Allergens

! dust mites

! pollen

! animal dander

! cockroaches

! feathers

! tobacco smoke

! other smoke (wood stove etc.)

! grass

! mold

! other

! removes down bedding

! cleans air filters

! covers beds with plastic

! maintains humidity at 25-50%

! washes linens weekly at > 130° F

! wears a face mask

! keeps windows closed

! remains indoors

! uses air conditioning

! follows pollen counts

! restricts access to pets

! avoids pet exposure

! removes pets

! uses tannic acid solution

! avoids forced air heating

! removes feather bedding

! avoids mowing the lawn

! uses frequent bleach cleaning

! avoids exposure to trigger

! other

! Household Irritants

! cleaning fluids

! aerosol sprays

! perfumes

! other ______________

! avoids exposure to trigger

! other

! Exercise

Specify:

! premedicates

! avoids exercise

! other

! Medications

! aspirin

! NSAIDs

! beta-blockers

! other

! discontinues medication

! avoids trigger

! other

! Respiratory Infections

! Weather conditions ! Remains indoors

! other

! GERD ! Uses strategies to alleviate GERD

Specify:

! Foods

Specify:

! Preservatives/additives

! Occupational Irritants

5

STATEMENT OF MEDICAL NECESSITY

PATIENT NAME: DATE:

ADDRESS:

CITY: STATE: ZIP:

HOME PHONE: DATE OF BIRTH:

DIAGNOSIS (ICD-9): ! 493. __ __ ! OTHER (please be as specific as possible)

Patient Problem(s):

REQUESTED ASTHMA SELF MANAGEMENT TRAINING SERVICES (")

# Comprehensive asthma self-management instruction

(includes all items listed below)

# Peak flow monitoring instruction

# Medication administration instruction

(specify: # All meds # Specific meds )

# Medication adherence assessment, instruction and monitoring

Goals of Service Requested:

Number of Authorized Visits:

I consider these requested services to be a necessary part of the patient’s care for the following reason:

# new diagnosis,

# change in symptoms or condition which necessitates change in self-management, or

# re-education or refresher training.

Physician’s Signature Date

PHYSICIAN NAME (PRINT):

PRACTICE ADDRESS:

TELEPHONE: NPI:

6

(Billing Cover Letter)

{Pharmacy Letterhead}

{Date}

{Insurance Company Billing Address}

Dear ________________:

I am requesting payment for respiratory care service provided at ______________ Pharmacy as summarized below:

Patient Name:

Patient Address:

Plan Name/ID Number:

Date of Service:

Expected Outcomes:

Supporting documents enclosed:

1. CMS1500 claim form

2. Statement of medical necessity

Please submit payment to:

{Pharmacy Name and Address}

Tax ID number: {Pharmacy Tax ID number}

Sincerely,

{Pharmacist Typed Name and Signature}

7

RESPIRATORY DIARY

Date

Comments

Rate Each Symptom

None = 0 Mild = 1 Moderate= 2 Severe= 3

List symptoms to monitor and medications. Check off each time a medication is used.

Controller Medications Quick

Relief

Symptoms

8

ASTHMA ACTION PLAN

GREEN ZONE: ALL CLEAR ! This is where you should be every day.

Peak flow between

(80% to 100% of your

personal best)

No symptoms of asthma. You

can keep up with your usual

activities and are able to sleep without symptoms.

Take these medications:

Medicine

How much to take

When to take it

YELLOW ZONE: CAUTION ! You need to take action to get your asthma under control.

Peak flow between

(50% to 80% of your

personal best)

First, take this medicine:

Medicine

How much to take

When to take it

You may be coughing,

wheezing, feeling short of

breath, or experiencing

chest tightness. You may be

finding it hard to keep up

with normal activities or

having difficulty staying asleep at night.

Next if you feel better in 20-60 minutes and your peak flow is over ______

(70% of your personal best), then take this medicine:

Medicine How much to take When to take it

Keep taking your Green Zone medications, too. But, if you DO NOT feel better in 20 to 60

minutes or your peak flow is under _________(70% of your personal best), follow the Red Zone

plan. If you go into the Yellow Zone often, tell your doctor. Maybe your Green Zone medications

should be changed to help keep you out of the Yellow Zone. Remember, there is no parking in the

Yellow Zone.

RED ZONE: MEDICAL ALERT ! This is an emergency! Get help immediately!

Peak flow between

(50% or less of your personal best)

First, take this medicine:

Medicine

How much to take

When to take it

You may be coughing,

wheezing, feeling short of

breath, or experiencing

chest tightness. You may be

finding it hard to keep up

with normal activities or

having difficulty staying asleep at night

Next, call the doctor to find out what to do at this point. But, see the doctor RIGHT AWAY or go

to the emergency room if any of the following happens:

• Your lips or fingernails are blue.

• You are struggling to breathe.

• You do not feel any better 20 to 30 minutes after taking the extra medicine and your peak flow is still under ___________ (50% of your personal best).

• Six hours after you take the extra medicine, you still need an inhaled !2- agonist every 1 to 3

hours and your peak flow is still under _________ (70% of your personal best).

Adapted from the National Asthma Education Program, Clinician’s guide: teaching your patients about asthma. National Heart,

Lung, and Blood Institute, National Institutes of Health.

9

PREDICTED AVERAGE PEAK FLOW RATES

CHILD AND ADOLESCENT MALE: Age 6 to 25 years Height (in.) 44 48 52 56 60 64 68 72 76

Age 6 99 146 194 241 289 336 384 431 479

8 119 166 214 261 309 356 404 451 499

10 139 186 234 281 329 376 424 471 519

12 159 206 254 301 349 396 444 491 539

14 178 226 274 321 369 416 464 511 559

16 198 246 293 341 389 436 484 531 579

18 218 266 313 361 408 456 503 551 599

20 238 286 333 381 428 476 523 571 618

22 258 306 353 401 448 496 543 591 638

24 278 326 373 421 468 516 563 611 658

25 288 336 383 431 478 526 573 621 668

CHILD AND ADOLESCENT FEMALE: Age 6 to 20 years Height (in.) 42 46 50 54 57 60 64 68 72

Age 6 124 164 193 223 245 268 297 327 357

8 153 182 212 242 264 287 316 346 376

10 171 201 231 261 283 305 335 365 395

12 190 220 250 280 302 324 354 384 414

14 209 239 269 298 321 343 373 403 432

16 228 258 288 317 340 362 392 421 451

18 247 277 306 336 358 381 411 440 470

20 266 295 325 355 377 400 429 459 489

ADULT MALE: Age 25 to 80 years Height(in.) 63 65 67 69 71 73 75 77

Age 25 492 520 549 578 606 635 664 692

30 481 510 538 567 596 624 653 682

35 471 499 528 557 585 614 643 671

40 460 489 517 546 575 603 632 661

45 450 478 507 536 564 593 622 650

50 439 468 496 525 554 582 611 640

55 429 457 486 515 543 572 601 629

60 418 447 475 504 533 561 590 619

65 408 436 465 494 522 551 580 608

70 397 426 454 483 512 540 569 598

75 387 415 444 473 501 530 559 587

80 376 405 433 462 491 519 548 577

ADULT FEMALE: Age 20 to 80 years Height (in.) 58 60 62 64 66 68 70

Age 20 357 372 387 402 417 432 446

25 350 365 379 394 409 424 439

30 342 357 372 387 402 417 431

35 335 350 364 379 394 409 424

40 327 342 357 372 387 402 416

45 320 335 349 364 379 394 409

50 312 327 342 357 372 387 401

55 305 320 334 349 364 379 394

60 297 312 327 342 357 372 386

65 290 305 319 334 349 364 379

70 282 297 312 327 342 357 371

75 275 290 304 319 334 349 364

80 267 282 297 312 327 342 356

10

AST$MA AND PEA+ ,-O/ MONITO1IN2 1ECO1D

$ea' (lo+ $er-onal /e-t1 22222222222222 l34in

6reen 7one1 890 : 100 ; o< =er-onal >e-t? 22222222222222 l34in : 22222222222222222 l34in

@ello+ 7one1 8A0 : 90 ; o< =er-onal >e-t? 22222222222222 l34in : 22222222222222222 l34in

Bed 7one1 8>elo+ A0; o< =er-onal >e-t? 22222222222222 l34in : 22222222222222222 l34in

Dee' o< 222222222222222222222222

"#$%&' ()$%&' *#+,%&' -+%$+,%&' *.#/,%&' 0/1%&' "&2#/%&'

EM $M EM $M EM $M EM $M EM $M EM $M EM $M

$ea' (lo+

BeadinG

8l34in?

SI4=to4-

JoKGLinG

DLeeMinG

JLe-t

tiGLtne--

SLortne-- o<

>reatL

Da'e at

niGLt +itL

-I4=to4-

Nn tLe a==ro=riate ti4e and date >oOP denote a 8Q? <or -I4=to4- eO=erienRed

11

!"#$%&'()&*+,,&

&

"#

!"#$%&! ()*+,!** %&#,

"#$%&' ()#*$#+' %, # -./000 ,12#*3 4556 7)#*$#+' %8 # ,292*9#8 ,6*%7 $#&&: ;6 +5$7363, <%6) +)#%8/ ,273*$#*=36

#8> >%,+5286 7)#*$#+%3, #8> )#, ,2++33>3> 9' 5443*%8? 4*%38>&'/ =85<&3>?3#9&3 ,3*@%+3: ;6 +2**386&' 4%&&, A/000

7*3,+*%76%58, 73* <33= #8> %, 5738 B58C"*% D 65 E #8> F#6: DCD: G)3 ,6#44 %8+&2>3, 583 42&& 6%$3 7)#*$#+%,6

HI5'+3 J 5<83*K/ 6<5 42&& 6%$3 7)#*$#+%,6, HB3&%8># #8> L#*5&K/ 6<5 42&& 6%$3 7)#*$#+' 63+)8%+%#8, #8>

6<5 7)#*$#+' +#,)%3*,:

M463* #6638>%8? # +3*6%4%+#63 7*5?*#$/ 6)3 7)#*$#+%,6 5<83* HI5'+3K >3+%>3> 65 %$7&3$386 # *3,7%*#65*' +#*3 ,3*@%+3:

G)3 5<83* )#, N-./000 #&&5663> 45* 6)3 4%*,6 6<5 '3#*, 54 6)3 7*5?*#$ #, %8@3,6$386 +#7%6#&: M 92,%83,, 7&#8 <#,

>3@3&573> <%6) ,73+%4%+ *3,758,%9%&%6%3, 45* %$7&3$386#6%58:

Business Plan for Family Pharmacy

Services Planned

M,6)$# #8> LO(P $#8#?3$386

;8)#&3*/ )5&>%8? +)#$93*/ 73#= 4&5< $363* #8> 8392&%Q3* 63#+)%8?

;84&238Q# @#++%8#6%58,

Goals of Service(s)

-: R8)#8+3 6)3 )3#&6) ,3*@%+3 %$#?3 54 6)3 7)#*$#+'

.: ;$7*5@3 6)3 +#*3 54 7#6%386, <%6) #,6)$# #8> LO(P

A: S*3#= 3@38 <%6)%8 6<5 '3#*,

T: L*3#63 # ,6*2+62*3 ,5 6)#6 ,3*@%+3, 45* 56)3* >%,3#,3 ,6#63, $#' 93 #>>3>

Target Start Date: 8 weeks from now

To be Done Implementation

Timeline Anticipated

Cost

Assigned To/

Comments

F%63 P3@3&57$386 #8> (*37#*#6%58

I3$5>3&%8?

Storage room conversion -needs to be repainted

! U " V 4 weeks $500 Royce

"2*8%62*3

Desk, three chairs, bookcase

! U " V 5 weeks $1500 (used) Melinda

R12%7$386

Peak flow meters ($12 x 2)

Demonstration holding chambers ($15 x 4)

! U " V 6 weeks $84 Carol

F277&%3,

Disposable mouthpieces, patient education

materials

! U " V 6 weeks $100 startup

$50 ongoing

Carol

In Store Logistics

(#6%386 +#*3 >5+2$386#6%58 ,',63$

Will use paper system

! U " V 6 weeks $50 startup

$25 ongoing

Carol

()#*$#+%,6 ,6#44%8?

1.5 hrs/month RPh time

! U " V 8 weeks 1.5 x $60/hr Royce

F6#44 %8+386%@3,

None at this time

" U ! V

G*#%8%8? 54 ,6#44 7)#*$#+%,6, 58 *3,7%*#65*' +#*3

NCPA online program

! U " V 4 weeks $0 Carol &

Melinda to

complete

G*#%8%8? 54 3$7&5'33, 58 7*5?*#$ ! U " V 8 weeks None Melinda

"3

A#ve&tisin+ an# P&omotion

In-sto&e !"#$%&"'( *+,,'"( +,- $#&,.'" $+"- ! 2 " N / 0''12 3455 M'78,-+

Patient – In store identification

!"# %&'()*&# +" %+, "-*..#&

! 2 " N 9 0''12 345 M'78,-+

P45sician 7 8i&ect mail

Ta&+ets: :4 ;+8, <"'$"8*'"2

! 2 " N = 0''12 3:55 M'78,-+

P45sician 7 8etailin+

Ta&+ets: !+,'2( >8778+;2( P+.'7

! 2 " N = 0''12 3=55 R#A$'

Ot4e& &e=e&&al sou&ces

" 2 ! N

?ebsite " 2 ! N

Ot4e&:

" 2 ! N

Reimbu&sement

8ete&mine =ees

! 2 " N D#,' N#,' R#A$'

8ete&mine met4o# =o& collectin+ pa5ment

=&om patient

! 2 " N / 0''12 N#,' R#A$'

Met4o# =o& =ilin+ an# t&acDin+ claims

Ebillin+ so=twa&e o& se&viceG

! 2 " N H weeDs A7"'+-A #0,

*8778,E

2#F.0+"'

R#A$'

Financials

Retu&n on investment anal5sis ! 2 " N D#,' N#,' R#A$'

T&acDin+ &evenues an# se&vice #elive&e# ! 2 " N G: 0''12 N#,' R#A$'

Evaluation of Service(s)

Revenue ta&+ets

EI<',2'2 +,- "'J',&'2 ."+$1'- $#,.8,&+77A +,-

'J+7&+.'- +,,&+77A

! 2 " N T# *'

$#;<7'.'- +F.'"

2.+".&<

R#A$'

Patient +oals

A-%'"',$'( %#2<8.+7 +,- ER J828.2 *'F#"' +,- +F.'"

',"#77;',.

! 2 " N T# *'

$#;<7'.'- +F.'"

2.+".&<

C+"#7

Ot4e&: " 2 ! N

On+oin+ Ope&ations

Polic5 an# p&oce#u&e manual

T# *' -'J'7#<'- +,- 1'<. &<M.#M-+.'

! 2 " N 9 0''12 +,-

*'A#,-

N#,' M'78,-+

A#ve&tisin+ an# p&omotion

C#,.8,&' 08.% 8,M2.#"' 8-',.8F8$+.8#,( -'.+878,E(

+,- -8"'$. ;+87 .# <%A28$8+,

! 2 " N 9 0''12 +,-

*'A#,-

3945 8,

2'$#,- A'+"

R#A$'

"#

"he %&''&()*+ ), the %)r,t dra%t &% the %)*a*c)a',2 attr)34ta3'e t& the re,5)rat&ry care 5r&+ram2 &% the 34,)*e,, 5'a*8

94m3er, )* : ; )*d)cate a '&,,

!"#!$%!% '!() *$! '!() +,*

<em&de')*+ =>>8>> >8>>

?4r*)t4re @=>>8>> >8>>

AB4)5me*t CD8>> >8>>

Pa5er d&c4me*tat)&* ,y,tem a*d ,455')e, =>8>> F=8>>

Gdd)t)&*a' Pharmacy ,ta%%)*+ reB4)red Hear @I @8= hr,Jm&*th K LM>Jhr N @F

Hear FI F8F= hr,Jm&*th K LM>Jhr N @F

@>C>8>> @MF>8>>

O455')e, @>>8>> =>8>>

Pharmac),t tra)*)*+ >8>> >8>>

GdPert),)*+ a*d 5r&m&t)&* @Q=>8>> C=>8>>

+-./0 !1234535 6776899 :;6;899

<=)!>+ )!?!$@! '!() *$! '!() +,*

Pr&d4ct <ePe*4e, !ear &: ( new asthma prescriptions 3 &4 fills 3 78 gross profit:fill ; <

new holding chamber prescriptions 3 75 gross profit:fill ; < new peak

flow meter prescriptions 3 75 gross profit:fill

!ear 4: &< new asthma prescriptions 3 &4 fills 3 78 gross profit:fill ; A

new holding chamber prescriptions 3 75 gross profit:fill ; A new peak

flow meter prescriptions 3 75 gross profit:fill

RFD8>> @S=C8>>

Pr&%e,,)&*a' ?ee, !ear &: A< AB minute patient visits 3 7E5

!ear 4: 5E AB minute patient visits 3 7E5

@MF>8>>

FDQ>8>>

+*+(A <=)!>+ )!?!$@! B:;66899 B6CDD899

=$<=)!>+ )!?!$@! '!() *$! '!() +,*

"e* 5erce*t &% re,5)rat&ry c4,t&mer, are *e( 5harmacy c4,t&mer, Tar)a3'e Tar)a3'e

U*crea,ed c&m5')a*ce a*d 5er,),te*ce ()th 5re,cr)3ed med)cat)&*,

)*crea,e, 5re,cr)5t)&* rePe*4e a*d c4,t&mer P),)t,

Tar)a3'e Tar)a3'e

+*+(A =$<=)!>+ )!?!$@! E E

+*+(A )!?!$@! B:;66899 B6CDD899

#)*F=+ GB:C:9899H BC76I899

15

AD#U%TMENT% TO ,U%INE%% .LAN

C#$%&'( )% $((*+,-).%(/ 0',1'2)$-' 1'+.3'4)%& $%3 5*1%)-*1' .6'1 7 8'$1(

EXPENSES YEAR ONE YEAR TWO

9'+.3'4)%&:;*1%)-*1' <.6'1 7 81(= >??@?? >??@??

AB*),+'%- C>@?? ?@??

P$,'1 3.2*+'%-$-).% (8(-'+ $%3 (*,,4)'( 7?@?? E7@??

A33)-).%$4 P#$1+$28 (-$55)%& 1'B*)1'3 G'$1 H/ H@7 #1(:+.%-# I JK?:#1 L HE

G'$1 E/ E@E7 #1(:+.%-# I JK?:#1 L HE

H?C?@?? HKE?@??

S*,,4)'( H??@?? 7?@??

P#$1+$2)(- -1$)%)%& ?@?? ?@??

A36'1-)()%& $%3 ,1.+.-).% HN7?@?? C7?@??

Total Expenses 3064.00 2945.00

DIRECT REVENUE YEAR ONE YEAR TWO

P1.3*2- 9'6'%*'( Year &: ( new asthma prescriptions x &4 fills x 78 gross

profit:fill ; < new holding chamber prescriptions x 7? gross

profit:fill ; < new peak flow meter prescriptions x 7? gross

profit:fill

Year 4: &< new asthma prescriptions x &4 fills x 78 gross

profit:fill ; A new holding chamber prescriptions x 7? gross

profit:fill ; A new peak flow meter prescriptions x 7? gross

profit:fill

OE>@?? HP7C@??

P1.5'(().%$4 ;''( Year &: A< AB minute patient visits x 7E?

Year 4: ?E AB minute patient visits x 7E?

HKE?@??

E>N?@??

TOTAL DIRECT REVENUE $2544.00 $4188.00

INDIRECT REVENUE YEAR ONE YEAR TWO

T'% ,'12'%- .5 1'(,)1$-.18 2*(-.+'1( R'2.+' %'S ,#$1+$28 2*(-.+'1(

T$1)$R4' T$1)$R4'

I%21'$('3 2.+,4)$%2' $%3 ,'1()(-'%2' S)-# ,1'(21)R'3

+'3)2$-).%( )%21'$('( ,1'(21),-).% 1'6'%*' $%3 2*(-.+'1 6)()-(

T$1)$R4' T$1)$R4'

TOTAL INDIRECT REVENUE ? ?

TOTAL REVENUE $2544.00 $4188.00

PROFIT $520 $1243

"#

!"#$%!&'(!) +&!" ,-#%."## $/&.

SERVICES PLANNED

GOALS OF SERVICE(S)

Target Start Date:

To be Done Implementation

Timeline

Anticipated

Cost

Assigned

To/Comments

Si$e De'elop+e,$ a,. P0epa0a$io,

Re+o.eli,2 ! Y ! N

F60,i$60e ! Y ! N

E86ip+e,$ ! Y ! N

S6pplies ! Y ! N

In Store Logistics

Pa$ie,$ ca0e .oc6+e,$a$io, s;s$e+ ! Y ! N

P<a0+acis$ s$affi,2 ! Y ! N

S$aff i,ce,$i'es ! Y ! N

T0ai,i,2 of e+plo;ees ! Y ! N

A.'e0$isi,2 a,. P0o+o$io,

I,-s$o0e ! Y ! N

Patient — In store identification ! Y ! N

Pa$ie,$ B Di0ec$ +ail ! Y ! N

"#

!d#ertisin* and -romotion

Physician — Direct mail

Targets:

! Y ! N

Physician — Detailing

Targets:

! Y ! N

Other referral sources ! Y ! N

Website ! Y ! N

Other: ! Y ! N

Reimbursement

Determine fees ! Y ! N

Determine method for collecting payment from patient ! Y ! N

Method for filing and tracking claims (billing software or service) ! Y ! N

Financials

Return on in#estment analysis ! Y ! N

4rackin* re#enue and ser#ice deli#ered ! Y ! N

7#aluation of Ser#ice:s;

Revenue targets ! Y ! N

Patient goals ! Y ! N

Other: ! Y ! N

Ongoing Operations

Policy and procedure manual ! Y ! N

Advertising and promotion ! Y ! N

18

RETURN ON INVESTMENT ANALYSIS

DIRECT EXPENSES YEAR ONE YEAR TWO

Remodeling

Furniture

Equipment

Supplies

Patient care documentation system

Pharmacist staffing

Staff incentives

Training of employees

Advertising and promotion

INDIRECT EXPENSES YEAR ONE YEAR TWO

Overhead attributable to program

[%Sq ft of space x % of time used = % of total store overhead or

percentage of total sales attributable to program = % of total store overhead]

Total Expenses

DIRECT REVENUE YEAR ONE YEAR TWO

Product Revenue

Year 1: ____ new asthmas prescriptions x 12 fills x $ __ gross profit/fill

Year 2: ____ new asthmas prescriptions x 12 fills x $ __ gross profit/fill

Year 1: ____ new holding chamber/peak flow meters

prescriptions x $ __ gross profit/fill

Year 2: ____ new holding chamber/peak flow meters

prescriptions x $ __ gross profit/fill

Professional Fees

Year 1

____ patient visits at $___

Year 2

____ patient visits at $____

TOTAL DIRECT REVENUE

INDIRECT REVENUE YEAR ONE YEAR TWO

Can choose to include some indirect revenue from other purchases

each patient might make during a visit

TOTAL INDIRECT REVENUE

TOTAL REVENUE

PROFIT

19

RESOURCES ASTHMA

Allergy and Asthma Network/Mother of Asthmatics, Inc. (AAN/MA)

800-878-4403

www.aanma.org

AAN/MA is a non-profit asthma and allergy health association. They provide educational programs and materials to

assist families and individuals coping with asthma and allergies. Members receive a monthly newsletter (The MA

Report), a 10% discount on AAN/MA publications and resources, coupons for asthma products, and access to a toll

free hot line.

American Academy of Allergy and Immunology (AAAI)

800-822-2762 Allergy Information Referral Line — provides patients with the name of an allergist in their area.

800-9-POLLEN Pollen and Mold Report Hotline. National Allergy Bureau. Provides patients with information

about pollen and mold levels in their area.

www.aaaai.org

The AAAI serves the public through information on asthma and allergies, as well as provides referrals to allergists.

There is a charge to the public for all publications. Pharmacists can receive bulk supplies of publications at no cost.

Allow 4-6 weeks for delivery.

American Lung Association

800-LUNG-USA

www.lungusa.org

The oldest voluntary health agency, the American Lung Association (ALA) provides self-help programs for smokers

who want to quit. The ALA also actively supports legislation and information campaigns for the rights of

nonsmokers and conducts public education programs about the health effects of smoking. There is a charge for most

publications. Additional information under COPD.

National Heart, Lung and Blood Institute (NHLBI)

301-251-1222 (NHLBI Information Center)

www.nhlbi.nih.gov/nhlbi/nhlbi.htm

NHLBI plans and directs a nationwide program of research in the causes, diagnosis, treatment, and prevention of

heart, lung, and blood diseases. The National Asthma Education and Prevention Program (NAEPP) operates in

collaboration with more than 20 professional, patient, and voluntary organizations. These groups are working

together to raise awareness that asthma is a serious chronic disease and to educate the public about its symptoms,

diagnosis, and management.

NHLBI is one of the 11 National Institutes of Health and part of the US Department of Health and Human Services.

All NHLBI publications can be reproduced in whole or in part without permission. If you do reprint NHLBI

publications, please cite the National Heart, Lung, and Blood Institute as your source.

Website has Asthma Management Model System (clinical practice guidelines, teaching/learning tools, research

library, patient education, and continuing education sections). Can download many of the NHBLI asthma

publications from website.

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National Institute of Allergy and Infectious 4isease (NAI4)

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?lobal Initiative for Asthma (?INA)

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www.goldcopd.com

+he Global Initiative for 8hronic 9bstructive <ung Disease (G9<D) works with health care professionals and

public health officials around the world to raise awareness of 8hronic 9bstructive Aulmonary Disease (89AD) and

to improve prevention and treatment of this lung disease.

G9<D Aublications (all are available in ADF format on website)

! Global Strategy for the DiagnosisE FanagementE and Arevention of 89AD. Scientific information and

recommendations for 89AD programs.

! Executive SummaryE Global Strategy for the DiagnosisE FanagementE and Arevention of 89AD.

! Aocket Guide to 89AD DiagnosisE FanagementE and Arevention.

! Ihat Jou and Jour Family 8an Do About 89AD. Information booklet for patients and their families.

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www.thoracic.orgLgoLcopd.

American +horacic SocietyLEuropean Respiratory Society +ask Force. Standards for the Diagnosis and Fanagement

of Aatients with 89AD. Nersion 1.2. New Jork: American +horacic SocietyS 2004 Vupdated 2005 September XY.

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www.lungusa.org

+he American <ung Association website has good patient education resources and tips for helping patients with

89AD deal with activities of daily living. +he A<A sponsors 89AD support groups (Zetter Zreather 8lubs) around

the country.