Executive Summary
More than 9% of children in the United States have asthma, and many repeatedly have flare-ups that land them in the emergency room or a hospital bed. Several pediatric asthma researchers suggest case management solutions to help families catch symptoms before crises occur.
• Case managers can work with families and children with asthma in schools.
• Case managers can educate teachers, school nurses, and families about asthma triggers and symptoms.
• When an area is struck by a natural disaster, such as what happened with Hurricane Katrina, it’s important for CMs to visit families in their homes in order to get a more accurate picture of the asthma triggers the children are exposed to.
Childhood asthma is a growing and challenging problem nationwide, and many states and healthcare organizations are beginning to look at case management models for keeping asthmatic children from having symptom flare-ups that result in emergency room visits and hospitalizations.
More than 6.8 million children in the United States have asthma, representing 9.3% of all children, according to data from the Centers for Disease Control and Prevention (CDC) in Atlanta.
Asthma management is one area where case managers can help a pediatric population make significant improvements in health, as well as reduce emergency room visits and unnecessary admissions to hospitals. Under the Affordable Care Act, case managers have the opportunity in some areas to work with their pediatric asthma populations in community settings.
For example, CMs can work with families and schools. “We found that children’s asthma management improved when a case manager or nurse practitioner was within the school and working with the child’s parents or primary care physician or a combination of both,” says Mary Friend, MSN, RN, CePN, pediatric nurse at Cincinnati Children’s Hospital Medical Center. Friend was a coauthor of a study of techniques for improving medication management in elementary school-age children with asthma.
“Working with them to coordinate the child’s care and making sure they are getting proper medications helps to improve management of those children,” Friend says. “Some interventions included teaching teachers and school principals. A combination of everything worked best.”
In Louisiana, a study of the Head-off Environmental Asthma in Louisiana (HEAL) program found that comprehensive case management, including asthma education, symptom management, and other strategies helped children with asthma whose lives were interrupted by Hurricane Katrina.
“Case managers went into the homes and connected all of these individuals in the optimum manner to promote wellness and asthma control,” says Lisa Linville, DNS, FNP-BC, APRN, JD, assistant professor at the Loyola University School of Nursing in New Orleans. HEAL was conducted after Hurricane Katrina and supported through some state funding and grants, Linville says.
Community case managers were recruited into the HEAL study from various agencies. The CMs had experience with children and some were from social work backgrounds, Linville says.
“Because they were dealing with so many socioeconomic issues and funding and financial issues, CMs were not there to provide healthcare,” she says. “Their primary purpose was to provide a bridge to key individuals and to maintain contact while giving support to many families after Hurricane Katrina.”
One of the challenges in working with pediatric asthma patients is that medical treatment and dosage levels are not as well understood as they are for adults, says Stanley Szefler, MD, research medical director and director of pediatric asthma research in the Breathing Institute at the Children’s Hospital Colorado, and professor of pediatrics at the University of Colorado School of Medicine in Aurora.
Also, parents and healthcare providers can miss the earliest signs of asthma in preschool age children, he notes.
“There is a lot of emerging asthma that occurs before age five, so looking for the early signs of asthma is important for that age group, as well,” Szefler says.
Some healthcare organizations and states are focusing on projects that connect children with asthma with community-based interventions that are handled through case management services.
“We’ve been looking at the school system for about 10 years,” Szefler says. “It’s an evolving program that some call community-based participatory research, and some might call it population health management.”
The program uses patient navigators, he adds.
“In our system they were health techs in the school system — nurse’s assistants,” Szefler says. “And we taught them more about asthma so they could interact with the community — schools, parents, children — and do more in the area of one-on-one teaching and communication.”
The advantages to approaching population health in that way is that it places support in the environment where there’s most opportunity for making an impact, he says.
“The doctor only has the chance to spend a small amount of time with the patient in the office,” he says.
Research of community pediatric asthma programs suggests that an effective method is to provide weekly coaching, teaching, and monitoring of the asthmatic patients, Friend says.
Families received information from their primary care provider and then shared it with their child’s school, she explains.
“They made sure school nurses and teachers were aware of the child’s asthma action plan, what the triggers are, and when they need their rescue medications,” Friend says.
Szefler’s research also has focused on understanding asthma within the school setting. One goal was to help school nurses become comfortable with asthma management, including assessing the severity of asthma and supporting the treatment plan.
“This is another source of support for disadvantaged children whose parents rely on emergency rooms and are more susceptible to hospitalization,” Szefler says.
State Medicaid programs and healthcare programs that focus on population health can have a big impact by meeting with children and families in their communities, Szefler, Friend, and Linville say.
“At Cincinnati, we see a lot of kids with poorly managed asthma,” Friend notes. “Symptoms are not recognized quickly enough, and they’re not given their preventive medications — either long term or short acting meds.”
These children end up in the ICU when their asthma is not controlled, she adds.
“Most of what we see could be prevented,” Friend explains. “So we were just looking for ways to help parents recognize the symptoms and help them intervene sooner, before the children get to the hospital — because once they get to the hospital, their condition is pretty severe.”
In a literature review study, researchers found that some of the things that were preventing parents from intervening in the cases of childhood asthma were a lack of education on symptom recognition or the parent’s denial that their child had asthma, Friend says.
“We found that there were parents who didn’t want to believe there was anything wrong with their child,” she says. “This was more frequent among minorities and those with lower socioeconomic status.”
In those cases, the children would return from the hospital and start having symptoms such as a dry, raspy cough. The parent might think the child had a cold, and wouldn’t treat for asthma. Then the child’s asthma would have progressed to the point that his or her airwaves were compromised and short-acting inhalers wouldn’t help with the symptoms. Even when the child reaches the point of being hospitalized, the parent still might not want to admit that there’s something wrong other than a respiratory infection. This was a common finding in the literature review, Friend says.
CMs working in areas struck by disaster — such as New Orleans after Hurricane Katrina — have numerous challenges, including finding children and their families, Linville notes.
Their days were spent calling families, trying to make appointments to meet them in their homes. People typically would say, “It’s not a good day,” or CMs would find that telephones were disconnected, Friend says.
“The child looks so different when you come to a clinic appointment because you don’t see the child’s home environment with pets sleeping in their bed and other asthma triggers,” she explains. “After Hurricane Katrina, we had families with homes that were full of mold; their houses were partially demolished, so people were living in one room of a house and had very little ability to clean it, or that were using bottled waters because their kitchens may have been devastated.”
There also were FEMA trailers that might have had some toxins and allergens and were not necessarily the best breathing environments for a child with asthma, Friend says.
One of the ways HEAL helped was to provide asthma counselors who were trained to go into homes and give families HEPA air filters and cleaning supplies to rid the homes of mold and allergens, Linville says.
“They’d establish goals to get pet hair cleaned up and get the pet out of the child’s bed,” she says. “They’d bring in clean linens for the child to sleep on and other supplies; they’d suggest pulling up carpets when these were damaged, and they’d help to recruit community support to help patients.”
Asthma counselors or case managers also could educate families on how to prevent environmental hazards, including using a reduced-rate pesticide company to get rid of cockroaches and other insects. They’d also talk about the hazards of smoking and how dangerous it was for the children with asthma, Linville says.
“If a family just went to the primary care physician, the doctor might not ask them about all of the potential environmental hazards, and the family might not mention them,” she explains.
When case managers were able to meet with a family at their home, they would sit and talk with the caregivers, assessing the environment and looking at the medications the child was taking. Then they’d write down the information, assess the peak flow reading, and see if the family needed additional instruction. If necessary, they might accompany the family to see the provider, she adds.
Childhood asthma is a growing and challenging problem nationwide, and many states and healthcare organizations are beginning to look at case management models for keeping asthmatic children from having symptom flare-ups that result in emergency room visits and hospitalizations.
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