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There’s a good reason the word "comprehensive" is a part of the title for the asthma management plan at Kaiser Permanente Medical Group in Rancho Cordova, CA. The program is a detailed step-by-step process designed to make all patients responsible managers of their disease no matter the barriers or motivation.
"We let them feel like they are designing their own plan. If people think that we will just tell them what to do and they have no say in their health care, we get no cooperation," says Jimmie Lucas, RN, charge nurse of allergy and immunology at Kaiser Permanente Medical Group Rancho Cordova.
Following is a description of the comprehensive process used to empower patients:
• Pre-visit contact is made by mail.
When a patient is referred to the Comprehensive Asthma Management Program, an appointment is set up for their first office visit. At that time, Lucas mails the patient a four-page questionnaire to obtain a brief asthma history for the physician. She also mails the patient a prescription for a peak flow meter and a spacer device for the patient’s meter-dose inhaler. The device fits between the inhaler and the mouth and helps patients breathe more of the medication into their lungs. The device increases medication utilization by 35%. "We find these two tools important in managing asthma," explains Lucas.
Patients bring the paperwork with them when they come for their appointment.
• RN educator sees patient first.
When the patient arrives for his or her appointment, Lucas makes sure that they are given a computerized lung function test to see how healthy their lungs are that day and a skin test to determine their allergies. "We find the skin test important because about 70% of all adult asthma is triggered by allergies," says Lucas.
While they wait for the results of the skin test, Lucas explains how the program works. Those who go through the program have access to an asthma specialist via telephone 24 hours a day, seven days a week. She also explains the purpose of an asthma action plan, which the physician will create that day. The plan is based on the patient’s peak flow readings, and his or her medications are adjusted according to the patient’s zone. The zones include green (well controlled), high yellow, low yellow, and red (emergency zone call asthma specialist or go to ED). (See example of Kaiser’s Asthma Action Plan for Adults in the educational insert.)
When the test results are in, Lucas begins the educational portion of the program. The curriculum includes basic anatomy and physiology of the lung and environmental management based on the patient’s test results. If the patient has no allergies, irritants and how to avoid them are discussed. Lucas has created a resource list for patients that includes national and local phone numbers for products to help the patient control his or her environment. For example, people who are allergic to dust mites can use a filtration bag on their vacuum cleaner. "Avoiding triggers and frequent medication as directed is what asthma management is all about," says Lucas.
• Physician sees patient following education session.
The physician sees the patient following the education session. At this time, the physician takes a detailed medical history, performs a physical exam, and writes a personal action plan for the patient based on peak flow monitoring.
For some patients, asthma is triggered by an infection, so the physician writes a prescription for future infections. The prescription is for an antibiotic that has worked effectively for that particular infection before. When patients have such an infection and their peak flow readings drop, they can fill the prescription.
• Following the physician visit, patients see a pharmacist.
With the aid of a machine, a pharmacist checks to see if the patient is using the meter-dose inhaler correctly. If not, the machine plays a tune. The pharmacist works with the patient until he or she gets the technique correct. At this time, there is also a review of the sequence of dose medication according to the zones on the asthma action plan. "Although the physician has covered this information, the pharmacist goes over it again because people get confused when they have three or four medications that they use at different times," says Lucas.
Finally, the pharmacist reviews the importance of each medication.
• A fourth member of the team is seen as needed.
A psychologist who specializes in behavioral medicine works with patients who have emotional issues. They may have a spouse who doesn’t believe they have asthma, or they are fearful and every time they become short of breath they run to the ED.
• Follow-up visits are scheduled.
Patients return to see the physician two to three weeks following their first visit. After the second appointment, visits are scheduled on an as-needed basis.
Each initial visit takes about 21¼2 hours per patient.