RI Asthma Control Program: Comprehensive Asthma Care

2. RI Asthma Control Program: Comprehensive Asthma Care Julian Rodriguez-Drix Program Manager

3. ASTHMA • An estimated 112,000 people in RI currently have asthma. • Adults: 15.9% lifetime, 10.8% current • Pediatric: 13.1% lifetime, 9.1% current • Cause and control related to indoor and outdoor environment • Disparities based on age, race, and income

4. Hospitalization Rates

5. Pediatric Hospitalizations

6. Age-Specific Asthma Hospitalization Rates Per 10,000 Population by Race/Ethnicity, 2010-2012

9. Asthma and Poverty • Asthma prevalence significantly higher in adults with an annual income less than $25,000 • The highest rates of poverty in RI cluster in urban areas • Highest childhood poverty rates up to 79%

11. Asthma and Housing • Housing conditions often linked with poverty • Known indoor asthma triggers • Mold • Smoke • Pest (mice and cockroaches) • Mildew • Neighborhood condition asthma triggers • Air quality: ozone, smog, exhaust, particulate matter • Stress and intense emotions

13. Asthma in Schools • Chronic absenteeism • Missing 10% or more of total school days per year • 37% of public school students with asthma were chronically absent from school in either 2010, 2011 or 2012 • Highest rates of chronic absenteeism cluster in urban areas • May reflect impact of other disadvantages of those with asthma

16. Asthma Care Guidelines • NHBLI’s NAEPP EPR-3 Guidelines: • From National Institutes of Health (NIH) National Heart, Lung, and Blood Institute • National Asthma Education and Prevention Program: Expert Panel Review • Proper diagnosis of severity, medication therapy, and assessment of asthma control • Asthma self-management education • Control of environmental factors Source: http://www.nhlbi.nih.gov/health-pro/guidelines/current/asthma-guidelines/full-report

17. Clinical Guidelines • EPR-3: Asthma Care Quick Reference • Initial Visit: • Diagnose asthma • Assess asthma severity • Initiate medication and demonstrate use • Develop written asthma action plan • Schedule follow–up appointment Source: http://www.nhlbi.nih.gov/files/docs/guidelines/asthma_qrg.pdf

18. Clinical Guidelines • Follow-up Visit: • Assess and monitor asthma control • Review medication technique and adherence; assess side effects; review environmental control • Maintain, step up, or step down medication • Review asthma action plan, revise as needed • Schedule next follow–up appointment

20. Assessing Asthma Severity (0-4)

21. Initial Therapies / Stepwise Approach: Asthma Patients 0-4 Years of Age D D Step 6 Preferred: High-dose ICS + either LABA or Montelukast OSC Step Up If Needed (first, check adherence, inhaler technique, environmental control) Recommend consult D Step 5 Preferred: High-dose ICS + either LABA or Montelukast D Step 4 Preferred: Medium-dose ICS + either LABA or Montelukast Consider consult Step 3 Preferred: Medium-dose ICS A Step 2 Preferred:Low-dose ICS Alternative:Cromolyn or Montelukast Step 1 Preferred:SABA PRN AssessControl Step Down If Possible (and asthma is well controlled at least 3 months) Mild Moderate Severe Intermittent Persistent Each Step: Patient education, environmental control, management of co morbidities If alternative treatment is used and response is inadequate, discontinue it and use the preferred treatment before stepping up ICS = inhaled corticosteroid; LABA = long-acting beta2-agonist; OSC = Oral Systemic Corticosteroids.; SABA = inhaled short-acting beta2-agonist.

22. Assessing Control (0 – 4)

23. Self-management education • Essential to provide patients with the skills necessary to control asthma and improve outcomes • Provide all patients with written asthma action plan that includes 2 elements: • Daily management • How to recognize and handle worsening symptoms Source: http://www.nhlbi.nih.gov/files/docs/guidelines/05_sec3_comp2.pdf

24. Self-management education • Regular review, by an informed clinician, of the status of a patient’s asthma control is an essential part of asthma self-management education • Encourage development and evaluation of community-based interventions that provide opportunities to reach a wide population of patients and their families, especially those at high risk

25. Comprehensive Asthma Care

26. HARP: Home Asthma Response Program • Pediatric asthma home visiting • Prior asthma related ED visit / hospitalization • Certified Asthma Educator (AE-C) and Community Health Worker (CHW) • 3 home visits: asthma self-management education, trigger reduction, environmental supplies • Results: improved health outcomes, reduced utilization/costs

27. BEAH: Breathe Easy at Home • Medical referral to code enforcement • For extreme situations when provider suspects that a child’s asthma is caused by housing conditions • Referral made through KIDSNET • Includes educational materials for family and landlord, legal support as needed • Currently available in four core cities: Providence, Pawtucket, Central Falls, Woonsocket

28. Certified Asthma Educators • AE-Cs play a critical role in team-based care • NAECB: National Asthma Educator Certification Board • Prep-courses offered twice per year • Encourage Nurse Care Managers, and/or other member of care team to become certified as an AE-C • Referrals for AE-Cs will be available through Community Health Network (like CDOEs)

29. Julian Rodriguez-Drix Program Manager, RI Asthma Control Program 401.222.7742 Julian.Drix@health.ri.gov