- Volume 10 | Fall 2012
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NACI Investigators Share Experiences
For many patients with asthma and their health care providers, delivering effective asthma care and control can be challenging. Progress is being made toward lessening the challenges, however, thanks to the dedicated efforts of 28 projects funded by the National Asthma Education and Prevention Program’s (NAEPP) National Asthma Control Initiative (NACI). These projects have implemented strategic activities and gained valuable knowledge about how to get health care providers, patients, and others to follow six key actions (based on the NAEPP’s clinical practice guidelines) that can chart a smoother course toward asthma control.
NACI project investigators spent two years putting the guidelines into practice in “real–world” settings.
What did they do and experience?
They set out to use the following main strategies and tactics:
- Changing and influencing systems using quality improvement approaches
- Engaging health care providers in training activities such as the use of spirometry
- Empowering patients and their families in asthma self–management education and in implementing home management strategies to control asthma triggers
- Facilitating partnerships among asthma stakeholders at the community level to promote synergy and scale up asthma care and control efforts
“We were able to modify and apply strategies that best fit our unique setting, which generated many lessons learned for the asthma control field,” said Stephen J. Teach, M.D., M.P.H., IMPACT DC Medical Director, Children's Research Institute, Children's National Medical Center.
The NACI launched its first group of projects in 2009 to develop, implement, and provide insight into strategies for accelerating the use of guidelines–based asthma care at the community level.
Getting the guidelines into practice is a high priority for the NAEPP. As noted by James P. Kiley, Ph.D., director of the Division of Lung Diseases, National Heart, Lung, and Blood Institute (NHLBI), "The guidelines give us the best that science has to offer about how to diagnose and control asthma, but unless health care providers, patients, and others integrate the recommendations into their programs and day–to–day routines for managing asthma, we will fall short of our potential to improve public health."
The NACI projects used the NAEPP’s 2008 Guidelines Implementation Panel (GIP) Report as a roadmap for overcoming barriers to guidelines–based asthma care. The GIP Report prioritized six key actions for putting the guidelines into practice, based on their feasibility and potential to positively impact asthma care and control (see box at right). Each of the NACI’s 28 Demonstration Projects, Strategic Partners, and Clinical Champions incorporated these six key actions through innovative strategies and tactics.
The ultimate goal of the projects was to promote the use of the guidelines to help improve asthma care and reduce the asthma burden in their communities—especially among groups that shoulder the greatest burden. Among their accomplishments, the projects:
- Boosted the number of providers who follow the guidelines for asthma care
- Improved patient outcomes through asthma home visits
- Enhanced quality and use of spirometry in primary care practices
- Increased health care provider knowledge and confidence in using the guidelines and communicating and promoting guidelines–based asthma care
- Developed and shared tools to streamline the guidelines and make them easier to implement
“Through the NACI, the NAEPP has shown that it can reach all corners of the United States with evidence–based asthma guidelines that improve the asthma care of patients everywhere, but especially in vulnerable communities,” said Mamta Reddy, M.D., director of the South Bronx Asthma Partnership (SOBRAP), a NACI Demonstration Project and Clinical Champion.
How did they do it?
At first glance, the NACI projects seem to have little in common. They targeted diverse audiences; operated in primary care practices, hospitals, homes, schools, childcare centers, and virtual (Web–based) settings; and implemented interventions in rural, minority, and urban communities.
What was the common denominator? They used the following same three questions as a guide for developing innovative methods for putting the guidelines into practice:
- How can we familiarize health care providers, patients, and other stakeholders with the NAEPP guidelines and six key actions effectively and efficiently?
- How can we provide intended audiences with useful tools that promote greater understanding and use of the guidelines in practice?
- How can we meet the challenge of individual and systemic barriers to the delivery of, and adherence to, guidelines–based care by patients and providers?
By asking these questions, project investigators were able to identify and overcome the patient, provider, and systems barriers identified by the GIP Report.
Some practical strategies that helped increase awareness and use of the six key actions to improve asthma care and control follow:
Adapting existing evidence–based tools and interventions
- The American Academy of Allergy, Asthma & Immunology (AAAAI) teamed with the American Academy of Family Physicians' National Research Network to adapt, test, and distribute AAAAI's Web–based ASTHMA IQ decision–support tool for primary care use.
- The University of Michigan Center for Managing Chronic Disease integrated the six key actions into its Physician Asthma Care Education (PACE) program, which had shown previously through two NHLBI–sponsored studies to improve asthma outcomes for pediatric patients with asthma.
- Dorchester House Multi–Service Center brought spirometry in–house for the first time after its entire Pediatric Department completed University of Washington’s (UW) spirometry program. Medical Care Development also began offering spirometry in its rural Calais, ME, practices after its total pediatric and adult medicine staff completed the UW program.
- Home asthma education and environmental control visits by Mission Hospital/Mission Healthcare Foundation in rural western North Carolina helped keep kids in school. An average 17 days missed per child dropped to 9 days missed after project participation. The Los Angeles Unified School District Nursing Services Asthma Program experienced even greater success, shaving the average number of missed days from 15.5 to 4.8.
Training and skills enhancement
- The Medical Society of Virginia Foundation’s (MSVF) Clinical Champions training and practice redesign initiative trained health care professionals working in primary care on how to apply quality improvement principles to incorporating the six key actions into their asthma care.
- The spirometry training and customized feedback program by the University of Washington (UW) improved the quality of spirometry testing. The four–month program was delivered to more than 200 primary care practices nationwide. Its goal was to educate staff in busy primary care settings on how to incorporate, perform, and interpret spirometry, an objective measure of lung function recommended for the diagnosis and periodic monitoring of asthma.
- Follow–up after trainings led by the National Association of Pediatric Nurse Practitioners, National Environmental Education Foundation, National Medical Association, South Bronx Asthma Partnership, University of California, San Francisco, and University of Washington has documented that participants had a greater depth and breadth of knowledge about the guidelines. In turn, these participants served as “champions” within their own institutions and communities, training thousands of other primary care providers and promoting guidelines–based care.
- Coaching. When coaching or academic detailing was provided as a follow–up to an initial training session, projects (including MSVF, SOBRAP, and UW) reported greater buy–in among providers and greater success at overcoming both individual and institutional barriers to guidelines–based care.
- Providing Maintenance of Certification credit. The American Academy of Allergy, Asthma & Immunology, American Board of Family Medicine, Medical Society of Virginia Foundation, and University of Washington reported that offering a Maintenance of Certification credit helped spur physicians and physician–led teams to engage in structured quality improvement initiatives.
- Leveraging electronic medical record (EMR) systems. HHC Woodhull Medical and Mental Health Center, for example, embedded guidelines–based elements into its EMR system and reinforced those elements with clinical training. As a result, nearly 100 percent of clinicians in the system used asthma action plans, leading to a 54 percent drop in asthma emergency department (ED) visits among 221 children seen in its Pediatric Asthma Clinic. Children’s Research Institute (CRI) at Children’s National Medical Center added an asthma encounter form to its EMR system to identify and document important elements of care during an asthma visit. This addition streamlined the exchange of patient information among CRI’s providers as part of its broader effort to transition patients with asthma from the ED to primary care.
Partnership development was critical for all of the NACI–funded projects, which shared their expertise and tools with one another and collaborated with community partners to engage target audiences. To illustrate:
- Allergy and Asthma Network Mothers of Asthmatics worked with local providers and organizations to recruit patients for its self-paced asthma education program.
- American School Health Association enlisted asthma experts from across the country to present its webinar series for school nurses.
- Asthma Allies recruited bilingual volunteers and trained them to assist its asthma educators in home visits with Spanish–speaking patients with asthma.
- Boston Public Health Commission coordinated with health care systems, community programs, and providers on a home visiting program.
- Education for Health partnered with the NACI–funded National Association of Pediatric Nurse Practitioners and two other nurse practitioner organizations to present its asthma course at their annual meetings.
- Michigan Department of Community Health enlisted physician champions to present its guidelines implementation tools at statewide conferences.
- National Asthma Campaign Foundation used electronic marketing, social media, and partnerships with other organizations to spread the word about is online educational videos for patients, providers, and the public.
Sharing their findings
To extend the reach and impact of these projects, the NAEPP’s NACI provided them with technical assistance, opportunities for networking and sharing resources, and a national communications infrastructure to distribute project strategies and results.
“The NACI, in essence, is a catalyst giving us the vision of the goal, and giving us the supporting tools that enable us to carry out this mission on the front lines,” said Michael Akerman, M.D., asthma program director at HHC Woodhull Medical and Mental Health Center (“Woodhull”).
With this support, not only were Dr. Akerman and his NACI colleagues able to test an array of strategies to meet the ultimate goal of improving asthma care and control, but they are also able to share their findings so that others can benefit from what they learned.
NACI project investigators and partners are working to make their tools and materials available to as many health care providers and others as they can through conferences, webinars, trainings, journal articles, and digital media.
“What we have learned collectively about implementation of the asthma guidelines through the NACI will be beneficial to health professionals, patients, and the community for years to come,” said Rachael Tracy, M.P.H., acting NAEPP coordinator for the NHLBI.
These projects have only scratched the surface of the GIP Report’s suggested strategies for overcoming barriers and facilitating effective, patient–centered asthma care. The NACI projects have shown a variety of ways to stimulate collaborative efforts that enhance implementation of the NAEPP guidelines. Improving asthma care on a broader scale, however, requires the continued commitment of a large contingency of asthma stakeholders, working together, to advocate for guideline–based asthma care for all people who have asthma.