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To increase patient compliance and reduce reliance on emergency services, administrators at Hartford (CT) Hospital’s Asthma Control and Education (A.C.E.) program knew they had to take a unique approach to asthma care, one that addressed the specific needs of their inner-city patient population. Utilizing the services of bilingual and bicultural nurse educators, A.C.E. has enlisted the help of community leaders, local agencies, and even landlords to develop a community focused program aimed at helping patients manage asthma in all aspects of their lives.
Founded in January 1997, the program has already yielded positive results. Prior to implementation of the program, no-shows for scheduled follow-up visits to the asthma clinic ran as high as 70%. With A.C.E., that rate has dropped to about 20%.
"When patients make contact with the program and with the people involved in it, their compliance is markedly improved," says Scott Wolf, DO, director of ambulatory medicine and education and medical director of the A.C.E. program. "That in turn affects their emergency room utilization. Instead of going to the ED when they’re having a problem, we find they are now calling us and coming in to see our nurse coordinator or their primary care physician. They’re not just relying on the ED as a safety net for them when they need that quick fix. They’re taking care of themselves on a daily basis, even if their asthma is not flaring."
While Wolf says that ED utilization and hospital admissions for asthma have dropped off "significantly," he’s reluctant to reveal exact figures until January 1998, when the full effects of seasonal variation can be analyzed. "There are certain quarters of the year, especially the quarter coming up, during the fall and winter months, when asthma rates rise," he says. "So it’s a little too early to tell."
The A.C.E. program is run by the hospital in partnership with Blue Cross and Blue Shield of CT. Most of the patients in the program are covered by the health plan’s Blue Care Family Plan, a capitated Medicaid arrangement. "From the hospital point of view, we would rather take the money from the cap to spend on education and prevention rather than to take more of the money out when these patients end up in the ED," Wolf says.
Patients are identified for the A.C.E. program through one of four avenues: ED visits, hospital admissions, referral from primary care physicians, or self-referral by the patient. "If they’re in the ED or they get admitted, all of the facets of our hospital, be it the nursing staff, the respiratory therapists, they’re all a part of our A.C.E. team," Wolf says. "So even if they’re seen first in the ED or in the hospital, the education and that contact with our program is made right there and then."
While some might consider the ED a poor place for patient education, Wolf disagrees. "It’s not a pleasant experience having to wake up in the middle of the night short of breath and go running to the ED," he says. I feel that if we can package up the concepts of our program in a five or 10 minute synopsis, they can understand and appreciate the discomfort they went through so that they can go home with the tools they need to prevent that from happening again." Like all of A.C.E.’s educational materials, the synopsis, called an Asthma Quick Guide is written in English and Spanish.
Once patients are identified, they’re given an official referral to the program and are scheduled for an initial one- to two-hour meeting with Patricia Hernandez, RN, the program’s bilingual asthma nurse coordinator. At that time, Hernandez takes the patient’s asthma history, smoking history, and various demographic information, all of which is inputted into a computer database. Patients also fill out a health status questionnaire and a baseline depression survey. Baseline spirometry also is conducted, and, soon, allergy testing will be done.
"Whenever you set up a disease management program, you have to understand who your population is," Wolf says. "About 70% of the patients that we service in our ambulatory center are Hispanic, and 90% of our asthmatics are Hispanic." Wolf adds that making the program bicultural and reaching out to Hartford’s Hispanic community has been to the program’s success. "The kind of bond our patients form with the nurse educator because of cultural unity is very important," he says.
Indeed, before Hernandez even begins to discuss asthma, she spends a sometimes considerable amount of time establishing a rapport with the patient. "For my patients in the Hispanic community, the last thing they want to talk about is asthma," Hernandez says. "They have to identify you as a friend first, as a person who really wants to do something with them. So they start telling me about a personal, social or economic problem. After that, they know that you listened, you answered, you care, and you respect them. Then you can start educating the patient."
Hernandez begins by stressing the chronic nature of asthma. While the disease can potentially be deadly if not managed properly, she tells them, "you can control it. And by controlling your asthma, you can control your life."
Early on, Hernandez found that, when asked to identify the inhaler they use from a poster in Hernandez’s office, her patients often don’t recognize the medication by name. "They recognize by colors," she says. "That’s one reason I use a lot of visual aids and analogies."
For example, in explaining how different medications affect the action of the lungs, Hernandez uses the analogy of a locked house. "In order to open the doors of your house, you need a key," Wolf says. "Bronchodilators, then, are the keys that open the lungs so that air can flow." Hernandez emphasizes the point by placing a sticker illustrated with a key on the medication. A doorstop sticker is used to indicate long-acting bronchodilators, which work for 12 hours.
Hernandez uses a third symbol, a broom, to indicate inhaled steroids. "When airs comes inside, you receive dust and a lot of bacteria, which start accumulating in your lungs the same way that dust accumulates on your floor," says Hernandez. "Well, in the same way that you sweep your house every day to keep clean, you have to use this medication to sweep your lungs everyday."
Finally, the oral steroid prednisone is indicated by a sticker depicting a vacuum cleaner, for use only when the house "gets really dirty," Wolf says.
Following the initial visit, a social worker visits the patient’s home to conduct an environmental assessment. The social worker takes note of such things as how many people are living in the home, how many are sleeping in one room, whether there are mattress covers and pillow cases, and whether the home has heating or air-conditioning. He or she also attempts to identify factors in the patient’s social environment that may be exacerbating their asthma.
"In other words, if we’re able to identify domestic violence or drug abuse or just poor living quality, we’re able to address those issues quite expeditiously because we actually have someone from our team who goes out and identifies these problems."
Fixing such problems, however, can be a difficult task under the best of conditions, Hernandez says. "It’s not like I can tell the patient, You have to move.’ We try to sort the situation out according to the possibilities." (See related story on dealing with environmental allergies, p. 134.)
Although such a community-based initiative can be labor-intensive, Hernandez believes it’s paying off. "Out of all my patients who used to go to the ED two or three times per month, only three continue to make regular ED visits. "One never came back for his [second] appointment. Another became allergic to the paint in her house. The other one is prednisone-dependent and just wants to come back to the ED for more prednisone," she says.
On the patient’s second visit, a nurse educator reviews the home assessment with the patient. The nurse also reviews what the patient learned during the first visit. Zone management is also introduced, with different colored stickers used to label the medications applicable to different zones. "There’s very little writing, and it’s very efficient for the patient," Wolf says. (See chart, p. 135.)
Patients also are shown various videos based on their educational needs. During a third visit, the nurse educator reviews and expands on previously learned material. Follow-up assessments are then conducted at three, six, and 12 months. At those times, spirometry is redone, and the quality of life and functional status questionnaires are administered again "to see if in fact we’re having an effect on their quality of life," Wolf says.
In addition, A.C.E. holds monthly group sessions at the Hispanic Health Council, where up to twelve patients engage in role-playing scenarios to help them identify appropriate responses to various situations concerning their asthma.
"It allows us to assess their understanding," Wolf says. "It also creates an environment that they’re comfortable with. They’re usually with people that they know from the community. They can ask questions in a comfortable setting and talk to each other about their experiences with asthma. It’s been quite successful because people really enjoy knowing that there are other people who have similar issues."
[For more information about the A.C.E. program, contact: Scott Wolf, DO, director, Ambulatory Medicine and Education, Medical Director, A.C.E. program, Hartford (CT) Hospital. Telephone: (860) 545-1223. Patricia Hernandez, RN, Asthma Nurse Coordinator, A.C.E. program, Hartford (CT) Hospital. Telephone: (860) 545-1223.]