Helping Providers to Improve Asthma Care

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Helping Providers to Improve Asthma Care
Pradeep Gidwani MD, MPHMatt Wimmer, MA San
Diego Childrens HospitalSan Diego Childhood
Asthma InitiativeSan Diego Regional Asthma
Coalition

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San Diego Pediatric Asthma Provider Education
Initiative

• Funded by the County of San Diego
• American Academy of Pediatrics, Chapter 3
• Program Components
• Parent Education Sessions
• English and Spanish, County-wide
• Traditional Continuing Medical Education Dinners
• Intensive Office Improvement Intervention
• Interactive Lectures
• Technical Support in Providers Offices

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Intensive Office Improvement Intervention

• SDPAPEI Team
• 3 Pediatricians
• Project Director
• (MPH/ worked for the Breast Feeding Coalition)
• Change Specialist
• (MA in Anthropology/Worked with NICHQ)
• Implementation Team
• Lost one of the pediatricians to clinical
  practice
• 2nd Pediatrician had limited time availability

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Development of the Intervention

• Solution based
• Our clinical pediatrician gave problems with
  the current system and approaches.
• We together brainstormed on ideas, developed the
  materials and tested them on our clinical
  pediatrician.
• Our clinical pediatrician kept hammering home
  It needs to be practical and simple.
• Stayed open minded
• Kept listening
• Focused on what can be done, not on what can't be
  done.

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Recurring Themes

• Improve identification of children with diagnosed
  asthma
• Improve classification of asthma severity
• Improve prescription of controller medications
• Increase use of treatment plans/school interface
• Increase use of other staff to educate parents
  about asthma

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The Intervention

• Two dinner meetings
• Dinner 1 Review of the NHLBI Guidelines and
  brief review of Quality Improvement
• Dinner 2 Asthma from the parents point of view
  and what works in your practice
• Technical support in between dinner meetings
• Visit to individual offices between dinner
  meetings

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Review of the NHLBI Asthma Guidelines

• Most providers feel like they know the
  guidelines developed by the National Heart, Lung,
  Blood Institute.
• We have found gaps still exist.
• We pitch the review as a time to start thinking
  about how to practically put the guidelines in
  use and what gets in the way.

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Quality Improvement Concepts

• Quality improvement is just a structured way to
  think about how to do things better power tools
  for making changes

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Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What changes can we make that
will result in improvement?
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Model for Improvement

• Aims

• Measures

• Ideas

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Cycle for Learning and Improvement
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The Improvement Cycle

• Plan
• Directly related to your aim
• What you think will happen as a result
• Define your efforts (who, where, when, what, and
  how) and measurement strategy
• Do
• Carry out the plan
• Document problems and unexpected observations
  (qualitative)
• Collect data for measuring your progress
  (quantitative)

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The Improvement Cycle

• Study
• Chart the data and analyze further if necessary
• Compare results to your predictions
• Summarize what you learned from the effort
• Act
• Continue the cycle in other areas,
• Modify your efforts based on your summary, or
• Start a new cycle

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Between dinner meetings Academic Detailing

• We visited offices individually
• Either lunch or breakfast
• Always brought food
• Focused on provider needs
• The project team spreads the learning
• Follow-up to see how things are going and offer
  further assistance

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Messages

• We are like drug reps, but all we are selling is
  good asthma care and making your lives easier.
• We know you cant work any harder.
• We are happy to customize materials for you. We
  know you are too busy to make changes. Just fax
  your changes to us.
• We are a resource for you.

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Messages (Continued)

• Its always good to start with small and build
  on your success.
• You know your practice better than we ever
  could.
• The tools we are sharing were developed by
  practicing pediatricians. We wish we could claim
  credit for them.
• If these tools do not work for you, let us know.
  We will develop something new for you. It where
  our best ideas come from.

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Tools Improving Classification

• Reminders
• Sticker for charts with emphasis on
  classification (pediatricians love stickers)

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Tools Improving Patient Education

• 1 page Asthma Basics
• Cover 4 main topics
• In Spanish on flip side
• Also developed Inhaler Basics how to use
  inhalers correctly

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Tools Improving Documentation

• Encounter forms
• Help to remind providers what to cover on each
  visit

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Tools Improving Information Exchange between
Patient and Provider

• Waiting Room Surveys
• Good for high-literacy populations
• Provide information to provider before visit even
  starts

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Tools Improving Controller Medication Use

• Severity Medications Chart
• Easy to consult guide
• Simplified, 1-page version
• Many of these tools are available at
  www.sdrac.org

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Second Dinner Session

• Activating Families for Effective Asthma Care
• To take time to think about asthma from the
  parents point of view
• To discuss and share strategies and tips for
  communicating effectively with parents
• Key Messages developed from parents concerns
• Interactive session so providers can learn from
  each other

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Who we reached

• We reached 42 offices
• We reached 157 people
• 82 Physicians
• 16 Nurse practioners
• 59 Ancillary staff
• Lead to Medical Assistant Trainings by our Asthma
  Coalition

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Evaluation

• SurveyMonkey.com
• Helped classify severity 71
• Changed medication prescribing 36
• Used treatment plans 88
• Other office staff educating 76

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What our customers have to say

• Thanks, finally someone has made the guidelines
  practical to use. I know them, but I dont use
  them.
• The best part of the program is that you come out
  to our office. By doing so, we are more
  motivated to change our practice.
• The team that visited our office made sure the
  tools fit our needs. Usually people (health
  plans) give you one set of tools and dont
  consider if it will work in your office. This
  team customized materials for us.

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What our customers have to say

• We are planning to implement all the tools
  provided. All of them are helpful.
• You can tell the tools developed had the input of
  people who are in practice.
• Very practical. Are you planning to add any
  other topics in the future?
• I am glad the AAP is leading this program. It is
  very helpful for those of us in practice.

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Whats Missing/ Next Steps

• A Good Evaluation (limited funding)
• We were unable to get enough chart reviews.
• We were unable to check actual changes in
  practice.
• We did not have access to important data
  elements.
• Developing partnerships with Childrens Primary
  Medical Group (in San Diego), Cincinnati
  Childrens, others?