Outreach improves patient satisfaction, retention
Asthma program succeeds where others failed
They are some of the most difficult patients: poor, reliant on government assistance, and suspicious of efforts to assist them especially when they come from government agencies. Getting them to accept help, particularly in a prevention program, is extremely challenging. But two agencies have started asthma outreach programs that have improved the specialty programs’ rate of locating and retaining these clients.
Sue Chapman, RN, BSN, MAHCA, director of maternal-child health at the Visiting Nurse Association (VNA) of Greater Philadelphia, has worked for the last six months on a new asthma program. A managed care payer provided the agency with a list of 52 patients who had been in the hospital or emergency room due to asthma. The VNA’s job was to locate these people and get them enrolled in the new program.
Of the 29 children on the initial list, 23 were located and 20 agreed to participate in the education and prevention program. Of those 20, 16 of them participated for the entire six months. There were 23 adults on the list, 16 of whom were located and 11 of whom agreed to participate in the program. Of the 11, eight lasted throughout the program.
Retention rate indicates satisfaction
Chapman has not yet done a formal patient satisfaction survey, but she views this retention rate as a nod toward patients’ satisfaction with the program. "These are people who were hard to find, hard to win over to the program, and hard to retain," she says. "The fact that they stayed involved and took part is a sign of satisfaction."
A similar program was started a year ago by Debbi Davis, RN, coordinator of the maternal child health program at NorthBay Health at Home in Fairfield, CA. There were 78 participants who ranged in age from 6 months to 85 years, all of whom are MediCal (the California equivalent of Medicare) recipients. Her retention rates also have been higher than expected for her target group.
Two-thirds of the participants (52) were children, and 26 were adults. "The referral base comes heavily from pediatricians," Davis explains, "and also from hospitals, which are more likely to admit a child for asthma than an adult." Of the 52 children, all agreed to participate in the program, and only two failed to complete it. The results for adults were not as startling 18 of the 26 agreed to take part, and of those, 14 completed the program.
"It’s hard with the adults, because they were not required to be home-bound, which goes against all the rules for home care, and also makes it harder to work the visits into their schedules," Davis says.
In the past, such programs were rare, in part because managed care organizations were loath to pay for prevention and education. The VNA, for example, had an asthma program, but it only consisted of a single visit after discharge from a hospital.
Last year, the VNA approached one of its payers and proposed a program that includes assessing the patient, the family, the disease’s effect on activities of daily living, and the home environment. The program includes four visits over a period of a month, then monthly follow-up telephone calls for another six months. The patient is given a quality-of-life survey at each end of the program. If there is not a positive change in the patient, then the payer is asked to authorize more visits.
The change that has allowed managed care to accept and even promote such programs comes from a realization that asthma costs a lot of time and money, says Davis. "It is one of the top three reasons for accessing medical care in California." For children, a trip to the emergency department usually leads to hospitalization and up to three days of inpatient care. "That’s around $4,000," Davis says. Without education, the scenario is likely to repeat itself.
Simple goals
The desired outcomes for both programs are simple. For Davis, they are to:
• decrease the number of asthma attacks;
• decrease the utilization of emergency department care;
• improve the patients’ activity level;
• help patients to sleep through the night without symptoms;
• keep medicine side effects to a minimum;
• keep peak flow readings within a desired zone.
While the data still are coming in, Davis says that by June, when final outcomes results are expected, there should be ample evidence of the program’s success. "Our pediatric wards used to be full of asthma patients," she says. "Now, they aren’t." Initial estimates project a 50% decrease in pediatric hospital admissions.
There are other indications that the program is working, she says. "We are getting referrals from all over the county."
At the VNA, the goals are to improve necessary skills, such as the ability to use a peak flow meter, a nebulizer, and an inhaler; and to understand the disease process, its triggers, prevention measures, and emergency protocols.
So far, interim information for the six-month-old program show that participating patients score at least three on a four-point scale for both skills and knowledge goals, says Chapman. Further data should be available later in the year.
Tracking patients from outside the system
For Davis, one of the biggest problems of the program development was the large participation from outside the NorthBay Health System. (See related story for advice on setting up a program, p. 17.) "It was really hard for us to track patients from outside our system and for us to see if they followed up with their own physicians when they were released."
Another problem also came from patients from outside NorthBay there was no standard referral form. "We found we needed more information on referred patients, like their emergency room history, whether they had ever had any education, or if they are just noncompliant," she says. "We had to develop a form which gives us more history information, and also ensures we know what equipment the patients have and what they need."
Davis is currently at work on such a form.
The age range of NorthBay’s patients also created challenges, and Davis had to create two programs with four acuity levels. The pediatric program includes these four levels:
• Level one.
This includes severely ill patients who get up to six nurse visits in a one-month period. The visits decrease in frequency as the patient and family gain understanding of the condition. There is unlimited telephone contact for progress and triaging between home visits during the first month. The nurses follow up every other month for six months to reassess the patient and monitor compliance.
• Level two.
These patients get three nurse visits in the first month and usually require less intervention. They also get unlimited phone contact during the first month, and then continue with the three bimonthly visits for reassessment and to monitor compliance.
• Level three.
This patient gets one home evaluation, including an environmental assessment for asthma triggers and evaluation of the patient and family understanding of the disease. Recommendations are reported to the patient’s case manager or primary care physician for follow-up and triage. No further visits are conducted unless requested.
• Level four.
This is for patients with moderate to severe asthma who had previously completed the home program, but have continuing problems. This acuity level includes another nurse evaluation visit and one to three follow-up visits, as indicated by the need for further education.
The adult program is almost identical, but there is no nurse triaging service available by phone. "Adults usually have less serious attacks," explains Davis. "The attacks are less likely to be life-threatening, and adults don’t need to go to the hospital as often. When they do need to go, they don’t need the triaging because they can more readily recognize when they need assistance than a child."
Another difference between the pediatric and adult programs is in the way a home evaluation is conducted. For adults, the home screening tool includes questions that can be answered by the patient with a yes or no. For children, there are fewer questions, and they are asked of the parent or caregiver. (See two sample screening forms, pp. 18-19.)
The biggest problem for Chapman, who is in charge of quality improvement for the program, was finding the target clients. "They were names on a list," she says. She solved the problem through a unique outreach program that has peers of the patients and their families locate them and encourage them to comply with treatment recommendations. (See related story, at right.) These outreach workers called lay home visitors also act as intermediaries between the nurses and the patients.
Other problems have also been noted, Chapman says, during monthly chart audits and regular meetings with the payer. For example, the quality-of-life survey includes some items that are inappropriate to the socioeconomic group involved in the program. "It asks about activities like skiing, tobogganing, and ice skating that our patients are not likely to engage in."
She also has to figure out how to deal with patients who don’t have phones, making follow-up phone calls impossible. And there is no education program in place for local school teachers, who can fight pediatric asthma by recognizing symptoms and helping children to avoid situations that trigger attacks, she says.
Pending hard data, Chapman says she uses gut instinct to tell her whether the program is successful. "I think there are fewer hospital trips for these patients," she says, adding that such a program can have startling results for the managed care organizations that are willing to pay for them.
"Asthma is one of those diseases that are completely controllable," Chapman says. "With education, there is no reason anyone should end up in the hospital because of an asthma attack."
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