(1) Quality Improvement Plans 

While Policies and Protocols are often necessary to clarify how aspects of asthma care need to be delivered, the use of broad QUALITY IMPROVEMENT PLANS is essential to assure that the entire process whereby asthma patients are served has been thoroughly reviewed and reorganized. This approach harkens back to the CDC’s “Standards for Pediatric Immunization Practices” formulated a decade ago in response to the realization that there was a marked discrepancy between providers’ perceptions of the success of their vaccination efforts and the reality observed in pediatric immunization rates.

(a) Pediatric Asthma Quality Improvement Plan 

As a participant in the Asthma Collaborative sponsored by the BPHC, the Hill Health Center of New Haven, CT developed this QUALITY IMPROVEMENT PLAN. Its goal is to take a comprehensive view of the way asthma care is provided at that Center and bring about system-wide change. Several of the tools that were developed for this project that are mentioned in this Plan are found below in the Asthma Forms section. Comments are welcomed. 

(b)     Asthma Flowchart  

Another participant in the Asthma Collaborative is Prairie Community Health in South Dakota.  They have developed a schematic to depict the optimal management of an asthma patient.  This Flowchart may be a bit unwieldy to download (or view) depending on your computer’s capacities.  If so, David Rollason is our contact there and can be reached at 605-466-2120 or at drollason@yahoo.com .

(2)   Standards for Asthma Management in the Schools

Standards for Asthma Management in the Schools is a set of guidelines modeled after the CDC’s Standards for Pediatric Immunization Practices which sets a series of goals for schools to optimally manage childhood asthma.  Accompanying it is a Provider Survey and Self-Assessment Instrument that permits schools to identify key components of Asthma Management Services that will help satisfy the Standards.  This tool was drafted for the New Haven (CT) school system and suggestions for improving it and the Survey are welcomed.  Any comments should be sent to supdegrove@snet.net 

II.  Asthma Forms: 

1.  ASTHMA ACTION PLAN
Asthma action plans are widely seen as an essential tool in the management of asthma as was demonstrated by a recent article in the American Journal of Respiratory and Critical Care Medicine that showed a 70% reduction in mortality among patients using them. We welcome feedback on these forms and will discuss comments we receive in future updates on this subject.

1. HRSA Work Group

Building on a template created by the Hill Health Center of New Haven, CT (which in turn was adapted from a form used by New York City’s Department of Health), the New Haven Asthma Coalition and the New Haven Health Department collaborated with a Work Group created by the Boston Field Office of HRSA to develop a MODEL ASTHMA ACTION PLAN. While this form may still undergo some fine tuning, it is recognized that each site may want to further amend it to meet their own particular needs. In addition, we have not yet translated this into other languages and this may necessitate further changes. It is recommended that those who wish to use this consider creating it as a tripartite form so that there will be copies for the provider, the patient and the school. 

(b)   Self Assessment Form 

This tool was developed at Prairie Community Health in South Dakota as part of their participation in the BPHC’s Health Disparity Collaborative on Asthma. 

In an effort to increase the usage of Asthma Action Plans and the sharing of this information with school health staff, the New Haven Health Department revised and combined two forms: the ADMINISTRATION OF MEDICATIONS IN SCHOOLS FORM, used to authorize medication administration by school staff, and the Hill Health Center’s ASTHMA ACTION PLAN. The coalition recognized that the ADMINISTRATION form was required of for any medicine administered in the schools and that they were used overwhelmingly to authorize asthma medications. The form includes two additional important features: (1) a section authorizing self-administration of medications by the student and (2) authorization for school nurses and, where they exist, school-based clinic staff to collaborate as a team in the management of the child’s condition. 

(d)   Assessment Form for Providers – South Dakota 

Another product of the Prairie Community Health’s participation in the Asthma Collaborative, this Assessment Form, like the one above, is for use in the patient’s chart to assess the status of the patient and update their care at each visit.

(e) Connecticut Managed Care Council Version

The form originally used by NY City, then adapted variously by both the Hill Health Center in New Haven and the New Haven Health Department, was finally further revised by the Connecticut Managed Care Council and mailed to  providers statewide.  It is being actively promoted by all of the managed care organizations for use throughout Connecticut.  The CT Chapter of the American Lung Association is now acting as the distributor and providers can contact the ALA for supplies for their offices.

The latest version contains a specific place for parents to sign to consent for nurses to contact primary care providers about the management of their child’s condition.  It is also available in both English and Spanish versions.

(2) ASSESSMENT FORMS FOR PATIENTS AND PROVIDERS 

It is now well recognized that many patients presenting in primary care settings suffer from previously undiagnosed reactive airway disease. Some of these patients have the cough-variant form while others with more classic symptoms simply have not come to medical attention before. In addition, many patients with asthma are inaccurately diagnosed with regard to their severity and consequently under treated. In an effort to capture these patients more thoroughly and treat them more effectively, ASSESSMENT TOOLS have been developed that can be completed by either the patient or one of the primary care team. These forms are commonly used at least once to assess the patient, but may also be incorporated into a program of periodic follow-up. 

(a) Self Assessment Questionnaire (2 versions) 

This tool was developed for at the Hill Health Center in New Haven, CT as part of their participation in the BPHC’s Health Disparity Collaborative on Asthma. The SELF ASSESSMENT QUESTIONNAIRE is available in both ENGLISH and SPANISH versions. As the Center was developing its asthma database, providers used it once for each patient as both an initial assessment and to capture the patient for the database.  

(b) ASSESSMENT FORMS FOR PROVIDERS

Also developed at the Hill Health Center as part of their participation in the Asthma Collaborative, these forms are placed in the chart and used to assess the status of the patient and update their care at each visit. The form has already been through several refinements and we have placed the two most recent ones here. Further revisions will be posted whenever they occur.  The FIRST FORM tries to combine information for several consecutive visits both to save space in the medical record and to allow for easy reference to information from previous encounters. On the back is an “Asthma Severity Code and Classification Chart” as a quick reference to providers to assist in both patient education and accurate recording of the patient’s diagnosis.  The SECOND FORM has but one visit per form and is more detailed.  It incorporates the severity scale as well as a ‘control’ scale and a listing of many of the most commonly prescribed medications into the form itself.  While a bit daunting to look at, its use of a largely check-off format allows the provider to obtain a considerable amount of data with a minimal investment of time.  The inclusion of the scales and medication list puts all the information the provider needs to assess the patient and make treatment decisions at his/her fingertips – increasing both the effectiveness and the efficiency of the encounter.

(c) Assessment Forms for School Health Providers

The New Haven Bureau of Nursing, who staff most of the city’s public and private schools, have made a significant commitment to improving the asthma management of its student charges.  In addition to developing the Standards for Asthma Management in the Schools and a version of the Asthma Action Plan/Administration of Medications in Schools form, both of which can be found above, they have created the following packet of forms (some new, some borrowed) to be used to assess and manage children with or suspected of having asthma.   Any questions about their use can be answered by calling the Bureau at 203-946-8167 or emailing them at phnurse@snet.net.

A Brief Summary of Use of the Asthma Forms

Assessment Sheet for Suspected Cases of Asthma

Asthma Assessment Sheet

Asthma Self-Assessment Form – English

                Cover Letter for Self-Assessment Form - English

Asthma Self-Assessment Form – Spanish

                Cover Letter for Self-Assessment Form - Spanish

Individualized Asthma Care Check List

(3) Patient Tools

This section will be devoted to tools and forms for the patient’s own use.  These may consist of patient reminders, records or other resources that assist the patient in the management of her/his asthma.

(a)  Little Air Peak Flow Diary

This form was developed by Veronica Mansfield and Mary Flannery at Middlesex Health Center in Connecticut with the generous support of AstaZeneca Pharmaceuticals.  It is for children’s home use and, employing the faces to record how they are doing, is useful at even rather young ages.

(b)  Patient Asthma Diary

Wanda Montalvo of NE Cluster Collaborative fame writes that “I continued to pursue the patient diary which we are supposed to provide to patients. The best copy I have found so far is on the NIH web site.  It is in the NAEPP Guidelines. They are in PDF format. You need to download it, or open it and print out page 37 only. There are 153 pages. This gives a great copy.  It is found at: www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.”

III. Asthma Education Resources 

Internet Downloads

1. Downloads for Children, Parents and Providers 

The Education Subgroup of the HRSA Asthma Workgroup has diligently combed the internet and found a wealth of educational materials that are downloadable. They have grouped these into three indices – for Children, for Parents and for Providers. The Group would appreciate any feedback on them that you might care to offer. 

INDEX FOR CHILDREN 

INDEX FOR PARENTS 

INDEX FOR PROVIDERS