Asthma

1. Asthma MANAGING ASTHMA IN SCHOOL Presented by Amy Zimmerman, Director Chicago Medical-Legal Partnership for Children, HDA

2. Background • Asthma is the most common chronic condition of childhood • 10 million children (13.5% of children <18 yrs) in the U.S. have asthma (NHIS 2006) • In some minority Chicago communities, as many as 1 in 4 children have asthma • Many have asthma that’s poorly controlled • Hospitalization, ED, mortality and morbidity rates higher in inner-city, minority Chicago communities

3. Healthy Home, Healthy Child (HHHC) • The Westside Children’s Asthma Partnership, Healthy Home, Healthy Child (HHHC),is a collaboration involving the Sinai Urban Health Institute, Health & Disability Advocates (HDA)/Chicago Medical Legal Partnership (CMLPC), and Metropolitan Tenants’ Organization (MTO). • HHHC seeks to reduce asthma mortality and morbidity by tackling the complex circumstances faced by the families of asthmatic children. • CMLPC provides free legal assistance to resolve issues that impact the family’s ability to properly manage their child’s asthma. • Comprehensive, individualized asthma education focuses on improving medical management (e.g., recognizing and responding to attacks, medications) and reducing exposure to home triggers • Community Health Educators make 6 home visits over the course of a 12-month intervention period

4. HHHC Participants Participant data • Average age of child is 7 • 91% of children are on Medicaid or Kidcare • Had an average of almost 3 asthma attacks and 5 wheezing episodes in 30 days • Had an average of 3.5 Emergency Room visits in the last year • Mother is the caregiver in 91% of cases • Only 15.4% had an Asthma Action Plan • Only 7.1% had a 504 plan.

5. What it takes to carry inhaler in CPS • Physician’s Request for Student to Carry Inhaler on Person • Physician’s Request for Self-Administration of Medication • Physician’s letter of diagnosis • Parent Request of Self-Administration of Medication

6. Public Act 096-1460 • School Code Amendment (105 ILCS 5/22-30) • Doctor's signature is no longer required for student to carry and self-administer asthma inhaler in school; only parent permission and prescription label are necessary. • Effective Date: 8/20/2010

7. Public Act 096-1460 part I • Section 5. The School Code is amended by changing Section 22-30 as follows: • Sec. 22-30. Self-administration of medication.    • (a) In this section:     "Asthma inhaler" means a quick reliever asthma inhaler. • "Self-administration" means a pupil's discretionary use of and ability to carry his or her prescribed asthma medication.      • (b) A school, whether public or nonpublic, must permit the self-administration of medication by a pupil with asthma or the use of an epinephrine auto-injector by a pupil, provided that:       • (1) the parents or guardians of the pupil provide to the school (i) written authorization from the parents orguardians for the self-administration of medication or  (ii) for use of an epinephrine auto-injector, written authorization from the pupil's physician, physician assistant, or advanced practice registered nurse; and   (2) the parents or guardians of the pupil provide to the school (i) the prescription label, which must contain the name of the medication, the prescribed dosage, and the time at which or circumstances under which the medication is to be administered, or (ii) for use of an epinephrine auto-injector, a written statement from the pupil's physician, physician assistant, or advanced practice registered nurse containing the following information: (A) the name and purpose of the medication or epinephrine auto-injector; (B) the prescribed dosage; and (C) the time or times at which or the special circumstances under which the medication or epinephrine auto-injector is to be administered.

8. Public Act 096-1460 part II • (c) The school district or nonpublic school must inform the parents or guardians of the pupil, in writing, that the school district or nonpublic school and its employees and agents are to incur no liability, except for willful and wanton conduct, as a result of any injury arising from the self-administration of medication or use of an epinephrine auto-injector by the pupil regardless of whether authorization was given by the pupil's parents or guardians or by the pupil's physician, physician's assistant, or advanced practice registered nurse. The parents or guardians of the pupil must sign a statement acknowledging that the school district or nonpublic school is to incur no liability, except for willful and wanton conduct, as a result of any injury arising from the self-administration of medication or use of an epinephrine auto-injector by the pupil regardless of whether authorization was given by the pupil's parents or guardians or by the pupil's physician, physician's assistant, or advanced practice registered nurse and that the parents or guardians must indemnify and hold harmless the school district or nonpublic school and its employees and agents against any claims, except a claim based on willful and wanton conduct, arising out of the self-administration of medication or use of an epinephrine auto-injector by the pupil regardless of whether authorization was given by the pupil's parents or guardians or by the pupil's physician, physician's assistant, or advanced practice registered nurse.

9. CPS Asthma Reporting • For years, 3% of CPS students were identified as having asthma • Most recently, a data run of IMPACT (student information system) showed 4% of CPS students have asthma • However, this rate may be much higher • For example, a study conducted in the 2007-2008 school year that surveyed 4,881 children citywide found that 13.56% of children have been diagnosed with asthma, while another 10.84% show symptoms but are undiagnosed; the same study conducted in the 2008-2009 school year (surveying 4,934 children) found that 18.06% of children have been diagnosed with asthma, while another 14.94% show symptoms but are undiagnosed. • Ongoing surveys conducted by the Mobile C.A.R.E. Foundation,

10. CPS Asthma Reporting • What Should Happen—and why it DOESN’T • Parent Completes Parent Section of DHS Certificate of Child Health Certification Form –or School Physical Form (required in k, 6, 9th grades) • Physician Reviews and Completes Form but may not review parent section; may be “mass” health screen event; even in ideal setting, docs are rushed/have many forms to complete • Child/Parent submits completed School Physical Form to child’s school • Nurse inputs School Physical Form information into CPS’ IMPACT system (overextended, only certain info may be input)

11. CPS Asthma Reporting • CAC’s School Task Force • Work with State to add asthma to physician section of School Physical Form • Lobby CPS or ISBE to adopt Asthma First Aid Poster as generic asthma action plan for students without AAP on file at school • Additional Potential School Task Force Projects • Lobby CPS to change policy on when asthma is entered into IMPACT (at self-carry, 504, and/or some other point?) • Streamline/consolidate forms that physicians are required to complete • Lobby CPS or IL State Board of Ed to make school physical form electronic and linked with CPS IMPACT system

12. Section 504 Plan Request Letter Pursuant to Section 504 of the Rehabilitation Act of 1973, I am writing to request an individualized evaluation on behalf of _________________________________who is diagnosed with asthma,to determine what services, accommodations, and modifications are necessary to include in a 504 Plan. I am requesting this assessment and 504 Plan due to the following concerns: □My child misses school frequently due to asthma. □My child visits the school health office frequently due to asthma. □My child has required emergency management of asthma (e.g. called 911, trips to E.R.). □My child’s asthma is triggered by school/classroom conditions. □My child’s asthma is affecting his/her learning. □My child cannot participate fully in P.E. activities. □The severity of my child’s asthma has changed. □My child needs to self-administer asthma medication/inhaler/medical equipment during school hours. □My child needs help administering asthma medication/inhaler/medical equipment during school hours. □Other: I have attached the following documents and am requesting that they be attached to the 504 Plan: □ASTHMA ACTION PLAN □Parent Request for Self-Administration of Medicationor □Parent Request for Administration of Medication to Student □The prescription label, including the name of the medication, the prescribed dosage, and the time or circumstances under which the medication is to be administered □Other___________________________________________

13. Childhood Asthma and SSI • Supplemental Security Income (SSI) is a federal government program that provides monthly payments to low-income families of blind or disabled children in addition to adults and senior citizens.  These benefits can be very important to low-income families who have children with asthma and have trouble affording rent and other basic needs. • The SSI disability standard used for children whose only medical problem is asthma (called the Asthma Listing by SSA) is very difficult to satisfy. Generally, attorneys are successful in getting benefits for these children in one of two circumstances: • The child has been seen in the emergency room six times during a 12-month period where the PRIMARY diagnosis is asthma or, better yet, asthma exacerbation. The number of admissions can be reduced if the child is admitted for more than 24 hours – in that case, such an admission counts as 2 visits. • The child has persistent low-grade wheezing between acute attacks and short courses of oral corticosteroids (e.g., Prednisone, Predisolone, or Prelone) that average 6 or more days per month for at least 3 months during a 12-month period.

14. Childhood Asthma and SSI: Role of Providers • It is very important for providers to keep this information in mind when writing medical records. • Better records will help claimants accurately describe whether they meet the Social Security Administration’s (SSA) asthma requirements. • The following actions would make it easier for severely/chronically asthmatic children to be awarded benefits: • Documenting wheezing on any examination in the office or hospital • Documenting the number of days the doctor has prescribed oral corticosteroids for the child to take as prescribed in the office, hospital or by telephone • Understanding that SSA looks to the primary diagnosis for determining that a visit counts as an asthma exacerbation

15. HHHC Findings • The Community Health Educators encountered a large number of environmental asthma stressors. Of the children participating in the HHHC program: • 36.1% were exposed to pests • 23.2% had mold or moisture in their homes • 57.5% were living with a smoker and another 36.8% had a primary caregiver who smokes • The MTO and CMLPC collaborations were generally well-received, but many complex socioeconomic issues have been beyond the scope of the project. Economic hardships create competing priorities for families: • 43.2% of families had an annual income of less than $10,000 • 62.0% of children had a primary caregiver who was unemployed • 69.9% of children had a primary caregiver who was single, divorced, widowed or separated

16. HHHC Results •  Preliminary outcomes through six months of intervention and follow-up show great improvements in the control and management of children’s asthma (N=142) including: • 73% decrease in asthma attacks • 75% decrease in wheezing episodes • 74% decrease in asthma-related emergency room visits • 73% decrease in hospitalizations • 45% less activity-limited days • 30% less school days missed due to asthma