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Winter, 2012

NACI Partner Profile

Asthma Action Plan Changes Lead to Nearly 100% Usage

The northern half of the New York City borough of Brooklyn is one of the most diverse areas of the nation, serving as home to many immigrant and working-class communities including large Latino, Polish, and Hasidic Jewish populations.

It’s also home to the Woodhull Medical Center (“Woodhull”), one of 11 hospitals in the New York City Health and Hospitals Corporation (HHC) network, and one of 13 National Asthma Control Initiative (NACI) Demonstration Projects.

As a result of its location, Woodhull has tailored many of its asthma materials to fit the language, culture, and other needs of this array of patients.

Equally important, Woodhull has adapted its asthma resources to fit the practical needs of the busy clinicians who serve these patients. An update to Woodhull’s existing asthma action plan (AAP), which is embedded in an electronic medical records system, yielded some of the greatest improvements.

Map of Brooklyn, NY

"We began modifying our asthma action plan in 2009, after we saw that it was not being universally used by providers," said Michael J. Akerman, M.D., a pulmonologist, Medical Director of Woodhull's Asthma Program, and the lead investigator on the NACI Physician Asthma Care Education and Reinforcement (PACER) demonstration project. "Since we made our changes, it's gone from less-than-optimal usage to nearly universal usage by clinicians."

What did Woodhull change?

They adjusted the electronic AAP screens after field testing the format with physicians. The most critical change steers the provider to choose the correct medication according to the initial classification of the patient's asthma severity. All the clinician has to do is choose the level of asthma severity in the electronic AAP, and a drop-down menu automatically appears beneath it. The menu lists the medications and dosages recommended for each step of care in the asthma guidelines issued by the National Asthma Education and Prevention Program.

“If they classify their patient correctly, it eliminates errors by guiding them directly to the appropriate step therapy medications,” said Dr. Akerman.

He also notes that after field testing this drop-down menu option, physician feedback led them to add brand names of medications alongside generic ones, for further clarity.

But the drop-down menu is not solely responsible for increased AAP use by clinicians. Dr. Akerman points to intensive training of hundreds of personnel in Woodhull's network as being part of the equation for success:

"We had to train every single physician, clinician, nurse, and nurse practitioner to teach them how to assess medication and device technique, as well as the asthma classification and control levels before they could write the AAP. We also taught them that the AAP is practically worthless if it is not properly reviewed with the patient at the time of the visit."

The trainings were a part of Woodhull's Physician Asthma Care Education Reinforcement (PACER) program, a NACI Demonstration Project that seeks to improve patient care through system-level changes that focus on educating the clinician first. These PACER trainings weren't just well received: They were requested, by both clinicians and patients.

In particular, the nursing leadership at Woodhull–North Brooklyn Health Network "warmly endorsed" the training, according to Dr. Akerman. As a result, the nursing department incorporated a lecture on asthma and 10 key questions on asthma medication, devices, and AAPs into the orientation for new hires.

From the patient side, there have also been requests for additional one-on-one training on AAPs.

And, there is evidence that this potent mix of training in conjunction with changes to the AAP upgrade has benefitted patients. Dr. Akerman reports that over the course of the project, the number of visits to Woodhull's Emergency Department has decreased by more than 50% among patients with asthma who are actively using AAPs—and have been trained by their clinician on how to do so.

“They’re better able to manage their asthma and not let it disrupt their lives,” said Dr. Akerman. "Whereas low literacy levels and socieconomic disadvantage were once thought to be impediments to active patient participation in health care, we have shown that these patients too are taking responsibility for their own health care, thus proving that behavioral changes can improve health care.”

Woodhull Medical Center's current PREP card for asthmaWoodhull Medical Center's current PREP card for asthma.

To engage patients actively in their asthma care—including to ask their clinician for a written AAP—Woodhull will soon release its updated PREP for asthma card. The card instructs patients what to expect from their physician and gives patients with asthma and their families questions to discuss with the clinician, including any problems since the last visit; the warning signs of an asthma attack; and telephone numbers for follow-up appointments, asthma education classes, and emergency care.

The Center has also translated the AAP into Spanish, to better serve an at-risk community that bears a greater asthma burden.

What’s the next goal? To spread the improved AAP to the 10 other HHC hospitals, so that their clinicians and communities can also benefit from this important tool.

Download or order a copy of the NHLBI's Asthma Action Plan.

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Last Updated February 2012




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