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When patients with severe asthma receive extensive patient education and close follow-up care, emergency room visits and hospital admissions can drop dramatically. You’ve probably heard that before, but now you can see it in action: A quality improvement project at the Burlington, MA-based Lahey Clinic slashed hospitalizations by 95% and emergency room visits by 87% in a year and a half.
At the Lahey Clinic, quality improvement has become an integral part of routine practice in many areas. But asthma specialists felt not enough attention was being paid to improving care for their sickest patients, so they formed a multidisciplinary team to study the issue.
"We were frustrated that we really didn’t have a good system for taking care of a certain fraction of asthma patients," says Andrew Villanueva, MD, a pulmonologist and critical care specialist who is director of the Lahey Clinic’s Asthma Center. "Most of the time asthma is a mild or moderate disease that you can take care of in a routine office visit, but there are some patients that really are quite costly. Between 5% and 10% of patients account for 70% to 80% of costs because they use the emergency room a lot and are hospitalized frequently."
The team — made up of pulmonologists, allergists, pediatricians, internists, emergency room physicians, respiratory therapists, nurses, pharmacists and quality resource personnel — included benchmarking in the process. External benchmarking included conversations with Boston-area physicians and a literature review, while internal benchmarking came through setting up data collection on four parameters: clinical outcomes, functional health status, patient satisfaction, and cost.
Data collection is ongoing in these areas, Lahey says. Clinical measures include number of prescriptions filled of beta agonists each month, use of anti-inflammatory medications, and average morning peak flows. The team wants to see patients using less than one canister a month of a beta agonist and to have 80% to 90% of patients taking anti-inflammatory medications. Functional health status is measured using the SF-36 quality of life survey as well as anxiety and depression scores. Satisfaction is measured through questionnaires for patients and soon, referring physicians. Cost will be measured on emergency visits and hospitalizations.
It’s clear so far that the dramatic reductions in two problem areas — emergency visits and hospitalizations — can be achieved through extensive education and a multidisciplinary approach to following patients, Villanueva says.
The Asthma Center accepts patients who have been hospitalized or have been to the emergency room twice in a six-month period for their asthma. The patients make an initial visit of about four hours in which they see all the members of the multidisciplinary care team: a nurse (who will be their nurse permanently), a pulmonologist, an allergist, a pharmacist, and a respiratory therapist.
The nurse takes the patient history on a standardized form, the pulmonologist looks at the medication regimen and any medical confounding factors that might be causing the symptoms, the allergist focuses on environmental aspects and skin testing, and the pharmacist goes over the medications. The respiratory therapist administers pulmonary function tests and watches how the patient uses a metered dose inhaler and peak flow meter.
At the end of the visit, the entire team meets to discuss the patient’s status and determine the cause of the difficulty, Villanueva says. The team comes up with a treatment plan, which the physician discusses with the patient before he or she leaves that same day. The nurse and pharmacist go over the details, especially the action plan for how to handle symptoms, as well as any changes in medications. The plan always includes keeping in touch with the patient’s primary care physician.
"[Patients] now have a person they can call if they have any questions or problems. Rather than going to the emergency room, they can call us and we can take care of the asthma flare ups at home or they can come to our office right away and we can help them," Villanueva says.
Deborah McManus, RN, an Asthma Center nurse, says the fact that patients see everyone on the team and hear the evaluation of their status on the same day makes a big difference. "Everyone gets different information from the patient, so collectively we have a better picture of the patient than we would separately," she says.
Patients leave that day with their medications, spacers, peak flow meters, or whatever equipment they need to control their asthma. Follow-up visits are scheduled within a month and then again four to five months later. "We empower the patients to take care of themselves and understand their own asthma," McManus says. "We want to make life as easy as possible for them."
Patients also go home with a binder that includes 24-hour phone numbers for accessing a nurse and a personal treatment plan that tells them what to do if their symptoms fall within certain zones. The nurses are responsible for much of the education process and can schedule return visits for the sole purpose of teaching something to a patient.
"We can reduce 70% of the problems over the phone," McManus says. "We develop a rapport with them that allows them to feel comfortable calling us."