Practice Nurse Teleconference

1
Practice Nurse Teleconference

• ASTHMA Cycle of Care in the General Practice
  Setting
• Jane Blundell CNC CWDGP

2
Learning Objectives

• At the end of this session the Practice Nurse
  will have
• A better understanding of the Asthma Cycle of
  Care
• An increased knowledge of who is going to benefit
  from an asthma cycle of care
• An improvement in their record keeping and
  documentation relating to asthma consultations.

3
Why do an asthma cycle of care?

• 2.2 million Australians have asthma
• More common in boys than girls (until puberty)
• More common in older women than men
• 385 asthma related deaths in 2007 (peak 964 in
  1989)(mean age 79)
• GPs, PNs, asthma educators and allied health
  professionals are central to good asthma
  management
• National Health Priority
• SIPs (Service Incentive Payments) are funded by
  Australian Government - 27.6m via Medicare.

4
What is an asthma cycle of care?

• Tool used in the general practice setting to
  improve self management and quality of life for
  people with asthma, by incorporating best
  practice management into a yearly cycle of care.

5
Who needs an asthma cycle of care?

• All people with asthma may benefit from the cycle
  of care as it incorporates diagnosis, medication,
  education, planning and review, however the
  Medicare item number for an Asthma Cycle of Care
  (Service Incentive Payment) may only be claimed
  for those people who have moderate to severe
  asthma. Other people can undergo the cycle but
  you would claim, for example, an item 36 for a
  long visit.
• Moderate to severe asthma includes
• Patients who use their bronchodilator more than 3
  times a week
• Patients using a preventer medication
• Patients who have symptoms on most days
• Patients who have presented to the ED or those
  who have been admitted to hospital for asthma.

6
Asthma Cycle of Care requirements

• At least 2 asthma related GP consultations
• Can only be claimed once each year
• Within 12 month time period
• One visit must be a planned review
• With completion of the following
• Documented diagnosis and assessment of asthma
  severity and level of control
• Review use of, and access to, asthma related
  medications and devices
• Provision of a written asthma action plan
• Provision of self management education
• Review of action plan, medication and asthma
  control

7
How can the practice nurse assist in this cycle
of care?

• The GP needs to see the patient for an Asthma SIP
  to be billed, however the PN can do a large part
  of the cycle of care depending on his/her level
  of competency.
• An example of how this can be implemented in your
  surgery is for the GP to see the patient for the
  first visit then refer to the nurse run asthma
  clinic for the second.
• Alternatively the nurse may search the patient
  data base and send out invitations, recall
  letters, put up a sign in the waiting room or
  what ever process works best in their setting.

8
How can the PN assist?

• By

• Taking a clinical history
• Performing spirometry
• Educating the patient on medications and devices
• Commencing a written asthma action plan
• Educating the patient to recognise signs of
  worsening asthma and how to respond
• Educating the patient on how to monitor their
  asthma
• Educating the patient to better identify and
  avoid triggers
• Explore what to do in an emergency depending on
  individual cirmcumstances

9
Documented diagnosis and assessment of asthma
severity and level of control

• When assessing asthma severity, the overall
  severity is assessed, not an attack.
• In adults the severity is classified as
• Intermittent where exacerbations are infrequent
• Mild persistent
• Moderate persistent
• Severe persistent
• For more details go to the National Asthma
  Council website
• http//www.nationalasthma.org.au/cms/index.phpere
  persistent

10
NAC Handbook p. 20

• Note Asthma severity here refers to the
  underlying,
• ongoing status of the stable asthma condition, as
• distinct from the severity of asthma
  exacerbations.
• A patient with mild persistent asthma might
• experience exacerbations ranging in severity from
• mild to severe. Severe exacerbations in a patient
• with mild persistent asthma usually occur in the
• context of multiple triggers, e.g. viral
  infections and
• exposure to airborne allergens.
• Asthma classification is a subjective assessment,
  so
• there is potential for variation of opinion
  between
• doctors. Patients perceptions of their asthma
• severity may also differ from those of their
  health
• care providers.

11
How to record in patients notes

• Write eg
• Asthma severity Moderate. Takes Blue
  reliever puffer x per week, wakes at night.
  Prescribed preventer.
• Keep it simple
• Use management section in MD for a easy to use
  template.
• Put into reason for contact Asthma

12
Review use of, and access to, asthma related
medications and devices

• To achieve the best control, with the lowest dose
  of medication, current use should be assessed
  regularly.
• Long term adjustment should be tailored to each
  patient
• Step down should be considered 6-12 weeks after
  good control has been achieved (use this as a
  reason for the patient to return for a review)
• Technique for medication/device use should be
  checked each visit.
• A comprehensive checklist and video of correct
  technique can be accessed through the NAC website
  http//www.nationalasthma.org.au/content/view/548/
  984/

13
How to record in notes

• List which medications are prescribed and what is
  being taken by the patient eg
• Prescribed Flixotide but not being taken at
  the moment educated on reason for continuing
  this medication. Encouraged to rinse and spit
  after taking preventer.
• Prescribed Ventolin MDI. Taken 3 x each day.
  Encouraged to use a spacer

14
Provision of a written asthma action plan

• The PN can assist the GP in writing a
  comprehensive Written Asthma Action Plan.
• The written asthma action plan should help the
  patient recognise deteriorating asthma and how to
  respond. They can be based on symptoms or peak
  flow measurements. They usually list medications
  and details on how to increase the reliever when
  symptoms deteriorate.
• NB A Written Asthma Action Plan is different
  from a GPMP as it lists the different stages of
  asthma control, triggers, signs of worsening
  asthma, what to do and where to seek medical
  assistance, changes in medication etc.
• Written Asthma Action Plan templates can be found
  on medical software of downloaded from the NAC
  website.

15
Why do a written asthma action plan?

• Evidence shows that
• Written asthma action plans improve asthma
  control, reduce days absent form work and school
  and for every 8 plans written, one after hours GP
  visit is saved and for every 20 plans written,
  one hospital admission is spared.
• Action plans are a useful tool to educate the
  patient. They show the different stages of
  control, how Peak Flow measurements drop when
  control worsens, they show, when and where to go
  for treatment and how much reliever medication is
  needed for each stage.

16
How to complete a written asthma action plan

• Find a suitable template
• Write in Patients and GPs details
• Write in triggers and best PEF if available
• Write the usual medication in the first column
• Reassure that it is safe to increase the reliever
  medication when asthma symptoms worsen (ask your
  GP for what they would like written)
• Educate the patient about who is the most
  suitable person to treat their asthma at each
  stage. Encourage self management but indicate
  when it is appropriate to seek medical help.
• Go through what to do in an emergency/encourage
  early treatment (ambulance or hospital) for
  severe/life threatening asthma

17
Provision of self management education

• Studies have shown that self management education
  will provide people with the knowledge and skills
  to better control their asthma, resulting in
  fewer emergency attendances at the surgery or
  hospital.
• Self management education should be tailored to
  each individual eg school children should know
  what to do on sports day or while travelling on
  the school bus, while the farmer needs to know
  that he may be at risk when shoveling grain.
• The patient may be referred to an asthma educator
  or pharmacist for education. If the patient has
  co-morbidities or complex care, you may consider
  using a GPMP/TCA as well as the asthma SIP (but
  do not claim within 3 months)

18
Review of action plan, medication and asthma
control

• The final requirement for the cycle of care is
  review of the patients asthma control, ongoing
  management and written asthma action plan. After
  the SIP has been claimed it is important to
  recall the patient for ongoing assessment.
• Symptoms and PEF (Peak Flow)
• Patient initiated changes so therapy can be
  reviewed
• Inhaler technique can be checked
• Education can be reinforced
• Asthma action plans can be reviewed and updated
• Trigger factors can be reviewed
• Lung function can be objectively assessed by
  spirometry

19
Medicare items

• All visits should be claimed as normal attendance
  items with the exception of the visit that
  completes the Asthma Cycle of Care. The SIP item
  number depends on the length of time it takes to
  complete.
• 2546 - Level B ( 23 100)
• 2552 Level C ( 36 100)
• 2558 Level D ( 44 100)
• DO NOT claim a normal item number as well as the
  SIP
• 11506 may be claimed on the same day if
  (pre/post) Spirometry is done
• If the PN is added to a TCA, a 10997 may be
  claimed for PN consultations. The GP does not
  need to see the patient during this visit if
  there are no problems detected.

20
Tips for record keeping

• To put a short cut on MD progress notes go to
  Progress notes.
• Click on management
• Click on add to list
• Enter details and name the file (eg 1 asthma, or
  2 asthma)
• This saves having to remember all the
  requirements of the Cycle of Care and can prompt
  such things as item numbers and when recalls are
  due.

21
The progress notes can be tailored for each
clinician

• Asthma Visit 1
• Severity
• Self management education given
• Triggers
• Devices education
• Asthma action plan written
• Spirometry (11506)
• Recall
• Bill usual item number

• Asthma Visit 2
• Review of symptoms
• Spirometry (11506)
• Review medication
• Review device technique
• Review triggers
• Reinforce education
• Bill item 2552
• Recall
• Referral

22
Tips to assist record keeping

• Go to progress notes
• Go to reason for contact
• Go to free text and enter Asthma visit 1 or
• Asthma SIP
• Dont forget to unclick the box marked active
• Leave in PMH

• For subsequent visits you can easily see what you
  have done by going to the past history tab.
• This lists activities and is an easy way
  to record 10997 visits 1-5 as well.

23
Tips for recording Spirometry

• 1. If your practice has a free standing
  spirometry machine, an easy way to record your
  data in your medical record is to go to
• tools
• tool box
• respiratory function
• NB you need to pre record height and weight

• 2. Click on manual
• 3. Enter PEFR, FEV1 and FVC both pre and post
  manouevers and save
• 4. This will automatically be transferred to the
  progress notes.

24
Summary

• Asthma Cycle of Care 2 visits in a year for
  someone with moderate to severe asthma
• After completion of the key elements claim a SIP
  (eg 2552)
• Practice Nurses can do much of the ongoing
  assessment and education
• GPMP TCAs can also be claimed for people with
  complex care needs (but do not bill on the same
  day as the Asthma SIP)