Vision: Interventions to Improve Education and Care
The vision of IMPACT DC begins with the notion that effective longitudinal asthma care is a broad continuum that involves many parties. At the center of this model is the patient who interfaces with his/her family, primary care physician (PCP), hospital, emergency department (ED), retail pharmacist, insurance case manager, and school nurse.
The ED can and should be a critical and integral part of this continuum, particularly for children who use the ED frequently and are poorly connected with PCPs and other sources of care.
Video: Asthma…research that helps asthma patients
Children's translational research that improves care for asthma patients. Discussed by: Jill Joseph, MD, PhD.
Intervention
The IMPACT DC Asthma Clinic is a unique ED-based asthma care source that operates continuously at Children’s. It sees children who are heavily dependent on EDs for episodic care, providing a comprehensive source of asthma education, medical care and care coordination designed to steer children towards healthier lives and more effective primary longitudinal asthma care.
The clinic sees children within two weeks of ED visits for acute exacerbations for a 90-minute visit where they meet with an asthma educator and a physician. While highly individualized and based on a shared dialogue with the family and the patient, the clinic’s curriculum is well scripted and highly reproducible. Taking advantage of the “teachable moment” that naturally occurs after the crisis of an ED visit, clinic staff focus on the three key elements of the consensus guidelines for asthma care developed by the National Institutes of Health:
Medical Care
Education on the basic physiology of asthma with emphasis on its chronic nature
Completion of an individualized medical action plan
Prescription of controller medications, as indicated by protocol
Device teaching (spacer, diskus, nebulizer), as indicated
Education on self-monitoring (by symptoms and/or peak flow measurement)
Provision of a peak flow meter and/or spacer, as indicated
Environmental Modification/Trigger Control
Education on the role of the environment and triggers in asthma
Specific education on the creation of a “safe sleep zone”
Provision of pillow covers
Tailored education on the following, as individualized for the family:
Tobacco smoke
Dust
Molds
Pests
Pets
Care Coordination
Education on the role and importance of longitudinal asthma care with a primary care provider
Services Provided
The multiple activities of the IMPACT DC Asthma Clinic are valuable in themselves, but coordination with primary care physicians (PCPs) and others in the care continuum is among the most crucial. This linkage between the ED and these caregivers represents an expanded role for the ED in which its activities are seen in the context of the broader systems of care for chronically ill children. To achieve such care coordination, we provide multiple services designed to improve and strengthen linkages between all those providing asthma care for the child. These activities include:
Creation of an individualized patient report (with an embedded digital photograph of the child) that is forwarded to the patient’s primary care physician, managed care asthma case manager and school nurse via fax and/or mail, as well as to the patient and family
Direct phone communication between the clinic physician and PCP when required
Scheduling of a follow-up PCP appointment within 4 weeks of the clinic visit
Scheduling follow-up appointments with the PCP and, as required, with sub-specialists who will provide further evaluation and treatment
Completion of school forms sufficient to allow child to receive reliever and controller medications in the school from the school nurse when appropriate
Children’s program is uniquely positioned to facilitate care coordination by leveraging existing relationships, particularly the District’s School Nurse Program and the Goldberg Center for Community Pediatrics. In fact, Children’s employs all public school nurses through the school nurse program and provides the school nurse of each IMPACT patient with an individualized asthma care plan for use while at school.
Similarly, for children without an identified primary care source, IMPACT works with financial counselors at Children’s to facilitate enrollment in Medicaid Managed Care. Through this process the team identifies a new primary care provider in Children’s healthcare system, which provides more than 50 percent of the primary care to Medicaid recipients in the District.
The IMPACT team rigorously studied this model of care to validate its efficacy in a prospective randomized clinical trial, which was accepted for publication in the Archives of Pediatrics and Adolescent Medicine, a JAMA publication. The study achieved several clinically and statistically significant outcomes:
Greater than 100 percent increase in the use of controller medications
Nearly 50 percent reduction in subsequent ED visits
Sustained improvements in numerous measures of quality of life
The next goal is to refine and to expand the trial, bringing even more partners into the process of reducing asthma morbidity among disadvantaged children.
History of IMPACT DC
IMPACT DC was founded in the fall of 2001 with funding from the Robert Wood Johnson Foundation to perform surveillance of pediatric emergency department visits for acute asthma exacerbations and to design and implement an intervention to address the problem in the District of Columbia. These efforts culminated in the creation of the IMPACT DC Asthma Clinic, a novel asthma follow-up care source physically located in the Emergency Department at Children’s.
IMPACT DC serves as one of 10 sites of the Inner City Asthma Consortium (ICAC), which studies immune-based asthma therapies in children and young adults. The team collaborates with the Center for Genetic Medicine Research on the AsthMap Project, which characterizes the genotypes and phenotypes of more than 1,000 asthmatic children in the Washington, DC, metropolitan area. Finally, the program collaborates with local inner-city pharmacies to study the effect of enhanced asthma education by community pharmacists. - Departments & Programs - Children's National Medical Center
