Asthma Center improves care with special project
ER visits down 56%, inpatient stays down 75%
The Asthma Center at the Lahey Clinic in Burlington, MA, is the brainchild of clinicians who couldn’t toss aside their concern about a group of asthma patients who showed up too often in the emergency room (ER) and on the inpatient units.
Andrew Villanueva, MD, of the clinic’s Pulmonary and Critical Care Medicine section calls the Asthma Center a "home-grown" program. "Usually programs like this start because the administration or quality department says to work on X.’ But in this case, we were frustrated because we knew we had a lot of people with the expertise to take care of asthma patients and we felt we were not doing as good a job as we could." In Massachusetts, the condition is classified as a preventable hospitalization.
The Asthma Center implements the National Heart, Lung and Blood Institute’s guidelines. Villanueva says it’s another instance of using what we know, in small ways, to achieve remarkable improvements. At Lahey, the improvements amounted to a 56% drop in ER visits and a 75% drop in inpatient stays. (For details, see the graph on ER visits and inpatient stays, p. 85.)
Most of the asthma patients at Lahey Clinic receive treatment from their primary care physicians. "Patients come in for their visits," Villanueva says. "Sometimes the nurse gets too busy to educate them. The doctor is certainly too busy to educate them."
Clinicians in the pulmonary section didn’t have any spare time on their hands either, but they decided they could improve asthma care even if they started with a modest effort. In reviewing the ER logs and inpatient census, the pulmonology staff identified 10 to 15 frequent repeaters who have no comorbidity. Having seen their primary physicians and "failed outpatient care," they were the pilot enrollees in the Asthma Center.
In early 1996, the interdisciplinary team convened and comprised pulmonologists, allergists, pediatricians, internists, nurses, case managers, pharmacists, and social workers. By late 1996, the Asthma Center was ready to roll out its program. Ever mindful of turf issues, the team contacted each potential patient’s primary care physician. "We were cautious because we didn’t want the primary care physicians to think we wanted to usurp their territory," Villanueva notes. "We showed them we wanted to partner, not take over, on their difficult asthma patients. In fact, we were surprised at the willingness of the primary care physicians to partner with us."
The Asthma Center offers patients an extensive (8:00 a.m. to 2:00 p.m.) initial visit including:
• evaluation by a pulmonologist and allergist;
• pulmonary function testing and skin tests for allergies;
• medications review and assessment by a pharmacist;
• assignment to a nurse who "owns the patient"
(Villanueva explains, "She or her surrogate receive the follow-up calls from the patient when they need help with their medications or if they have questions about their asthma.")
• team evaluation of each patient’s case;
• personalized asthma management plan.
("It usually comes down to education," Villanueva notes. "The patient doesn’t understand how to use the medications or what to do when the asthma gets worse." The backbone of the protocol is the self-care instruction and pairing each patient with a clinician who discusses problems with him or her.)
Each patient’s primary care physician is kept abreast of services his or her patient receives through the Asthma Center. Villanueva emphasizes, "This is state-of-the-art outpatient care; it’s nothing new. But it results in people using our [Asthma Center] services instead of the emergency room or the hospital."
Among key indicators continually monitored by the project team are the frequency of patients’ medication use, especially anti-inflammatory meds. A rise in those figures warns of self-care difficulties and a probable ER visit or hospitalization in the near future. "We can abort an emergency visit by having patients come to our offices during the day for intravenous steroids or a nebulized treatment," Villanueva observes.
Other indicators monitored include:
• episodes of depression and anxiety which often trigger asthma attacks;
• ER visits (down 77%);
• inpatient stays (down 89%); (For dollar figures, see graph, above left.)
• patient satisfaction ratings; (For two key ratings, see graphs on patient satisfaction, p. 84.)
• patient-based quality of life ratings, measured by the SF-36. (For an explanation of the SF-36. see QI/TQM, September 1998, p. 124.)
Villanueva is quick to caution that the team has no control group against which to validate its numbers. Nonetheless, he adds, "over four or five years, we should see a sustained reduction in the cost of asthma care."
As Villanueva reflects on the project, he reports three significant insights that will aid in future improvements:
1. The power of collaboration. "This is an opportunity for some of us who have worked together for years to hear and learn more about patient care from each other’s expertise," Villanueva says. "We always communicate by charts and by phone, but sitting down and talking about our patients teaches us to look at them differently."
2. Patients’ willingness to invest time in their care. Although initiation into the asthma program takes the better part of a day, feedback indicates patients are happy that providers spend the time to learn about them and teach them self-care methods.
3. Astonishing gains from a small start. Today’s Asthma Center is actually the second try at a program for difficult cases. "In the early 1990s, we had this grand plan, but it was too big, and we didn’t get off the ground," Villanueva explains. "Back then, somebody told us to start with modest goals and to build from there. That’s what we did with this program, and it worked.
"It was a mom-and-pop project," he continues. "All of us have a full practice. One frustration we have is not having much time to expand the program." To resolve the time problem, the Asthma Center team is negotiating with Lahey Clinic’s management to hire a nurse practitioner to coordinate a larger effort. The responsibilities would involve identifying and recruiting high-risk patients, collecting data, and maintaining communication with the primary care physicians. (For information on a pediatric asthma management project by a hospital in conjunction with a network of community-based pediatric practices, see QI/TQM, March 1999, p. 40.)
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