Collaboration to Help Our Children and Youth with S pecial Healthcare Needs

1. Collaboration to Help Our Children and Youth with Special Healthcare Needs Children’s Medical Services provides care-coordination, access to care and medical coverage assistance for children with chronic conditions. Partnership with other agencies and institutions to support health and functioning. CMS Pediatric Specialty Outreach Clinics Statewide: Pediatric specialty outreach clinics for asthma, cleft lip and palate, neurology, nephrology endocrine, genetics, cardiac and metabolic conditions

2. CMS sponsored Pediatric Asthma Outreach Clinics • Pediatric Asthma Outreach Clinic: “one stop shopping” • Children and Youth with moderate to severe asthma • UNMH clinic consultations are provided by the Pediatric Pulmonologist, Pediatrician, Respiratory Therapist, and an Asthma Nurse/Pharmacy Educator from the Pediatric Pulmonary Division of the University of New Mexico School of Medicine at the CMS/UNMH clinics • Spanish Language interpretation provided by CMS staff

3. Fox, et al (2007) Hypothesis: Effecting changes in the overall system of care for childhood asthma in community clinics would lead to improved clinical outcomes Goals: Introduce continuous quality improvement through multidisciplinary clinic-based team building, including community health workers Results: Improved asthma-related health outcomes by using a team-based approach using community health workers. • Patients reported fewer acute visits, emergency room visits, hospitalizations, frequent daytime/nighttime symptoms, missed school days. • Clinic-wide improvements in documentation of asthma severity, review of action plans, health services use, asthma symptoms. • Pediatrics, vol. 120, no 4 (October 2007)

4. The NE Region CMS/UNMH Pulmonary Project • multidisciplinary community partnership to address asthma management issues for children and youth • Contact school nurses to increase awareness re: students with moderate to severe asthma • Provide assistance with signatures on Asthma action plan and coordination with school staff to ensure follow-up with recommendations • CMS care-coordination provides consistency in medical care between family, primary care provider, school nurse and specialist consultation

6. The 2007 “Wrap Around” Model School nurses in NE Region have been invited to join the children/youth & family member to the outreach asthma clinics to attend the “one stop shopping” consultations with their student and family. Additionally, a didactic school nurse training was provided in the local communities (Santa Fe, Espanola, Las Vegas and Taos) by the UNM Pediatric Asthma Educators on the Management and Control of Asthma in Children & Adolescents

7. Why? • High prevalence of asthma and not enough services • Consistently long waiting lists to receive initial evaluation and follow-ups for children/youth referred to asthma clinic • Many children continued to need to be seen at clinic due to poor compliance with complicated and confusing medication protocols • Language barriers and literacy compound difficulty in mastering medication protocols • School nurses/school based health staff do not get information regularly re: updated medication regimen and often have difficulty connecting with families and coordinating asthma management for these children/youth within the school setting

8. School Nurse Comments: Several cases reported: “ …effective pre-medication of the children prior to recess and PE class resulted in children not experiencing asthma symptoms…” “…split between two schools, inevitably, we (school nurses) don’t have the information and the forms/asthma action plans are not completed in the students school record…It was very helpful to get permission forms signed by MDs for students to have their medications at school.” “Not only did I learn a lot, but helped to form a good medical partnership between the student, parent and me (school nurse).” “…wonderful to feel part of a team…” “A school nurse attended clinic with a student who had “a scary asthma-related emergency room visit in spring of ‘07 is now doing extremely well with asthma symptoms and did not have any medical/emergency room visit(s) in Spring of ‘08.”

9. NE New Mexico Results

10. School Nurses Make a Difference in Asthma Management and Treatment Plans!

11. Results The multi-disciplinary community partnership model has met the objective of promoting the medical discharge of more children from the clinic and therefore making more spaces available and serving more children/youth and their families Success in reducing the frequency of urgent care visits/hospitalization, reduce the number of days missed from school and reduce asthma symptoms for children/youth involved Creation of a multidisciplinary team approach to asthma management with coordination of care between families, primary care, school nurses and specialists

12. R2 PH Asthma Clinics * * *

13. Future Endeavors • Continue School Nurse involvement to support pediatric asthma (and/or other chronic medical conditions) management – specifically correct and effective use of asthma medications • Continue training of community providers including school nurses, promotoras, and primary care community • Continue care coordination activities to assure “wrap-around” support for children and youth with Asthma and/or other chronic medical conditions

14. The following scenarios would warrant a referral to the Children’s Medical Services Program for asthma care coordination (any other chronic medical condition could be substituted for “Asthma”): · Child has no medical home ( ie. no consistent primary care provider). · Child has no insurance and/or resources to pay for medication. · Child does not get to medical appointments for asthma (or other chronic medical condition) management. (However, a referral to CYFD is not warranted.) · Child and/or family does not have or provide to the school the appropriate asthma (other) medications and equipment for asthma (other) management. · Child and/or family members need more education on proper use of asthma (other) medication.

15. ContactsSusan Chacon, LISW Program Director505-476-8860susan.chacon@state.nm.usMadelyn Krassner, LISW NE Program Manager505-476-2667madelyn.Krassner@state.nm.usSusan Merrill, LISW NE Supervisor505-476-2644susan.merrill@state.nm.us