Asthma Care in At-risk Kids: Can an Emergency Department Lead the Way?

Laurie Scudder, DNP, PNP; Stephen J. Teach, MD, MPH

Disclosures

November 12, 2013

Editor's Note:
Asthma is a serious chronic illness that disproportionately affects urban, poor, and largely minority children and adolescents.[1] Too often, emergency departments (EDs) serve as the primary source of care for these kids. The result is higher costs and poorer long-term disease management.[2]

A fast-paced ED is typically not equipped to provide the fine-tuning of pharmacotherapy as well as the intensive child and parent education needed for symptom control and best quality of life. Children's National Health System in Washington, DC, decided something needed to be done. IMPACT DC is an innovative program that provides individualized education, improved coordination with a child's primary care provider and school, and community outreach, with a goal of reducing the need for ED visits and hospitalizations in these vulnerable children.

The program has captured the attention of the public in Washington, DC, and is earning praise throughout the community.[3] Medscape spoke with Stephen J. Teach, MD, MPH, Medical Director of the program, about program specifics, outcomes, and lessons learned.

Medscape: Can you begin by describing the specific components of the program?

Dr. Teach: IMPACT DC stands for "Improving Pediatric Asthma Care in The District of Columbia." It is a matrixed program of clinical care, advocacy and outreach, research, and education focused on the epidemic of uncontrolled asthma among, principally, inner-city, disadvantaged, and largely minority children and adolescents.

The centerpiece of our program is the IMPACT DC Asthma Clinic. It is a highly novel intervention that is centered in the ED itself. This originates from my background as a pediatric emergency medicine physician.

About a decade ago, my team and I became increasingly concerned about what we saw as a high and rising utilization of the ED for episodic care of asthma. This means that kids with asthma, the most common chronic disease of childhood, were using the ED very frequently for asthma exacerbations. These highly seasonal flare-ups occur most commonly in the fall, when children go back to school, and again in the spring, when allergies to tree pollen and other spring allergens are very common.

Many of these children, particularly those from disadvantaged backgrounds, develop unhealthy patterns of ED recidivism, using the ED over and over again for episodic care of their disease at the expense of the highly effective longitudinal care for asthma available in most primary medical care homes (PCMHs).

The simple idea that we had was to leverage our unique position as a valued and trusted source of care for many inner-city families confronting asthma in their kids. We reconceptualized our role to be a proactive part of the public health continuum.

The way we did this was quite simple. We noticed, and had good data to support this observation, that very few of the children seen in the ED for episodic flare-ups of asthma returned to their primary care providers for follow-up. Without this follow-up visit, the opportunities for improved and ongoing preventive care were never realized. Specifically, the kids weren't started on daily control of medications, educated about asthma, or educated about trigger identification and avoidance.

We did something that nobody else had ever done before. We invited the children and their families to come back to the familiar confines of the ED itself. No one had ever tried that, and the results were quite astounding. Follow-up rates in the ED were more than 3 times higher than they were when the families were asked to follow up with their primary care providers. It was a striking observation.

In addition, our centerpiece intervention, the Asthma Clinic, made very creative use of asthma educators. We had each family meet at great length with an asthma educator who would review the basics of asthma clinical care, the environmental influences on asthma, and the importance of care coordination, specifically within the PCMH. We worked in coordination with all the important clinical touchpoints of a child's life. Most important of these is the school nurse who, of course, sees the child for his or her medical care for a large portion of each school day. Other important parts of the network of care for that child include their community pharmacists, any subspecialists involved, and of course other practitioners and nurses within the child's PCMH besides their primary physician or nurse practitioner.

No one had ever tried this before. We conducted a classic randomized, controlled clinical trial to study our intervention.[4] We randomly assigned 488 kids to care within the IMPACT DC Asthma Clinic or the usual recommended follow-up care with the child's primary care provider. The results of that trial, which were published originally in 2006, were quite striking. There were dramatic drops in subsequent ED utilization and hospitalizations, and dramatic increases in the proportion of kids using daily controller medications and spacers to deliver those medications. There were also dramatic increases in asthma-related quality of life among the kids who attended the clinic. We had discovered that we were onto something, and so we took that program and made it part of our usual spectrum of care.

The IMPACT DC Asthma Clinic continues to grow. It remains based in the 2 EDs affiliated with the Children's National Health System: an ED at our main campus, and a smaller ED that is optimally located in one of the most disadvantaged parts of the city, which also happens to be the epicenter of the asthma epidemic among young children.

We feel that the quality of the services that we deliver to the families continues to improve as well, and the program has become a highly collaborative effort whereby physicians and nurse practitioners from multiple domains, including pulmonary medicine, allergy medicine, hospitalist-based medicine, general pediatrics, and emergency medicine, collaborate to see these children several mornings a week within the ED itself. Subsequent care, we hope, is delivered within the child's PCMH, and we try to ensure that through very robust case management services that each child receives before, during, and after their clinic visit with us.

In short, our entire conceptual model is to leverage a child's and family's familiarity and comfort with the ED to the child's ultimate advantage by using it as a follow-up destination, and a point of transition for the child from dependence on the ED for episodic care to dependence on the PCMH for ongoing effective longitudinal care.

Medscape: How many children in total does IMPACT DC serve, and for what period of time? Are children disenrolled from the program at some point?

Dr. Teach: We welcome over 1000 new families into the program every year. To be clear, what's highly unique about our program is that we don't strive to take over their care. We strive to transition their care from a model based on the ED for episodic care to the PCMH. Our care model is consultative and transitional. We don't seek to follow children for more than a month or 2.

Most of our children and families only need to come to the transitional IMPACT DC Asthma Clinic once. That visit is a comprehensive 90- to 120-minute visit that includes a very detailed and robust drill-down into the child's situation, looking at all the components of good asthma care: proper diagnosis, identification and control of triggers, development of a medical plan, and care coordination with all the elements of the child's primary and medical care team.

Some of our families we see for a second or third time to ensure that that transition is smooth and effective. But we are not a source of ongoing asthma care for families. Quite the opposite: We seek to provide short-term transitional care and get the kids back to their primary medical care providers.

We refer to subspecialists in a limited fashion, and this is particularly appropriate for children with severe persistent disease, who clearly have markers of disease that are likely to require ongoing subspecialist care. But our focus, in short, is getting the kids out of the ED and into their PCMH.

Medscape: How would you categorize the severity of asthma in these children? What percentage of kids have moderate to severe persistent asthma?

Dr. Teach: The majority of the children whom we see at presentation to the clinic have persistent disease, typically mild or moderate persistent asthma. A significant subgroup, however -- probably up to one third -- have intermittent disease. Remember, though, that in pediatrics, intermittent disease can nonetheless result in severe, dramatic exacerbations, typically on a seasonal basis -- most often in the fall.

This is an underrecognized problem for many of these children because most of the time, their disease does not cause them any day-to-day impairment. Most of the time, they appear fine. But once, twice, perhaps 3 times a year, they have dramatic, severe exacerbations that take them to the ED and frequently result in hospital admission. This is a group of special interest to our program, because our goal is to cut down on the number and severity of these exacerbations.

The risk that these children face on an annual or biannual basis from these acute exacerbations can be very significant. We have a unique vantage point to capture these kids, recruit them into the program, and help them identify their triggers, and perhaps control their disease through the use of daily controller medications on a seasonal basis.

For example, if the child with intermittent disease nonetheless has 1-2 severe dramatic exacerbations in the fall months, that's a child who may benefit from aggressive management steps in the fall to include institution of daily controller medications when the child returns to school, early vaccination for influenza, and careful steps to ensure that the child is exposed to a minimum amount of viral illness during their back-to-school months.

Medscape: You've discussed the metrics measured in the program. How long have you been collecting these data? How durable do the outcomes appear to be?

Dr. Teach: Our program was originally funded with a research grant from the Robert Wood Johnson Foundation, and we conducted our randomized clinical trial from 2002 through 2005. It was the very positive robust results that we got from that trial which convinced us that we are really onto something, and we needed to institutionalize this very unique and innovative program. Again, nobody else had ever done this before, but we felt that the city-wide metrics that we were collecting on ED utilization for asthma were really discouraging and getting worse, and so we needed to try something aggressive and different.

Ultimately, we were able to transition what was essentially a research intervention into a landscape of care for asthma in the district that has proven to be very effective. Now we have partnered very effectively with primary care doctors across the district and also in southern Maryland to target kids who clearly have out-of-control disease and are at risk for frequent exacerbations and hospitalizations. We recruit them into this very effective system of transitional care, which gets them educated on proper controller medications and reconnected with their PCMH.

During the middle part of the past decade, we were able, with the support of the hospital, local managed care companies, and philanthropies, to transition the program into a fee-for-service model, which continues to expand to this day.

What is really exciting now is that after more than a decade doing this work, we are beginning to see real population-based change. The rate of ED visits for asthma among DC kids with asthma has dropped an astounding 40% over the past 6-8 years. We are aware of no other city that has documented such a steep and sustained drop.

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