**Minutes: MCH conference call on ASTHMA - Wednesday Jan 21, 2004 \--
04:00 pm ET**

MCH coordinators and others include:

1\. Alaska -- Margaret Baldwin, CNM

2\. Aberdeen -- Mary Lynn Eaglestaff, RN

3\. Bemidji -- Mary Fairbanks

4\. Billings -- Diane Jeanotte, RN

5\. Phoenix -- Roy Teramoto, MD; Georgia Butler

6\. MCH HQE -- Judy Thierry, DO list manager and leader for the call

Call began with Guest participants:

**Dr. Patel, Pediatrician** and PH Consultant at Quentin N Burdick
Memorial Health Care Facility in Belcourt, North Dakota
<sandeep.patel@mail.ihs.gov>

**Dr. Tim Ryschon, Clinical Director** at the Rosebud Comprehensive
Health Care Facility

1.  **Access and Scheduling**: **One template or two template system?**
    Patient ability to identify and maintain relationship with primary
    provider or team appears to be dependent on scheduling system.
    Standard ER/walk-in/scheduled appointments allowed for lack of
    continuity, high no show rates, missed appointments, open clinic
    time, decreased provider efficiency and disruption of asthma
    management, over use of pharmacy for refills and under use of
    providers for comprehensive management plan. Rosebud uses a single
    template schedule. This has shifted patient care completely away
    from the walk-in paradigm. A single template means that the case
    manager and clinic manager have access to design of the schedule.
    The patients are told to schedule an appointment in say one to two
    weeks and it is their responsibility to call in and make the
    appointment. While this was an approach that required some "gritting
    of teeth" to move past the "what if they don't show up" phase, the
    whole appointment system was revamped to this type of scheduling. No
    show rates have decreased and patients are making appointments and
    being seen by their providers. Tim Ryschon can address further
    questions. <tryschon@rosebud.aberdeen.IHS.gov> Dr. Patel addressed a
    two -- template system which allowed for one template for scheduled
    visits and one for same day appointments. The no show rates were
    still elevated and the control of the schedule was left with medical
    records. From the discussion it appeared that the single template
    system was more effective. It did require top down and bottom up
    buy-in and promotion. Walk-in "clinic" at Rosebud no longer exists.
    As it had previously existed it was still held to ER -- EMTALA
    system guidelines and triage of patients. The new system has shifted
    all outpatient care to same day appointments and has segregated ER
    by itself.

2.  **Medical Home Concept:** This is a MCH patient population to have
    an identified provider and medical home. Where same day appointment
    system is in place patients can have access to the same provider.
    Medical home feasibility is linked to a system that provides access
    to care, follow-up. **Case management, staged asthma**
    **management** that is hospital or service unit wide, formulary,
    consultant access, community education, family support and
    consultation.

3.  No special forms are used at Quinton Burdick. Rosebud used the case
    manager to generate the active Asthma case lists and manage an RPMS
    asthma package. No pcc+ or special forms are used.

4.  Quinton Burdick provides Flu vaccination letters to all children
    with asthma; flu shot promotion campaign with posters featuring
    local community members. An Annual asthma outreach event (under the
    auspices of a community wellness event) provide smoking cessation
    info, present a lecture on management of asthma, and provide flu
    shots (this year, 2nd annual event \-- over 70 shots administered in
    that one night). Such How screening events, do not use spirometers,
    but use questionnaires, Health Educators, and CHR's and PHN's
    Infection control nurse has launched an initiative to increase flu
    shots in the adult patients via a nurse incentive program. Awareness
    of actual number of shots given / nurse caused a dramatic increase
    in overall numbers.

**Rosebud experience:**

5.  **First Tier**: Primary care providers who receive initial and
    ongoing orientation to the National standards of asthma management
    and case - by case and daily reinforcement of those standards,
    hospital morning report and CHS committee.

6.  **Second Tier**: Respiratory Therapist (RT) managed Asthma clinical
    case management program supervised by the chief of anesthesiology.
    Before the release of the RPMS asthma case management module, the
    case list and the status of the clinical domains was aggregated and
    managed in a standard Excel spreadsheet. With the release of the
    asthma package, the patient list has been migrated. Response:
    Rosebud is using an asthma case management package that has about
    300 cases. While the patients are encouraged and expected to make
    their appointments and followup -- the RT case manager provides a
    "sub-floor level" of monitoring to make sure people are not lost to
    follow-up completely. RT receives regular training and orientation
    in case management and interacts with a team of clinical case
    managers working on other disease conditions.

RT case manager provides focused case management, followup, staff
training, manage

the package. RT does not do nebs. Does do PFT's.

7.  **The third layer**: state-of-the-art formulary of \"controller\"
    medications. Refill process controlled with the same day
    appointments.

> [ASTHMA MEDICATIONS]{.smallcaps}
>
> [ASTHMA RELIEVERS: ALBUTEROL, IPRTROPIUM, LEVALBUTEROL, PREDNISOLONE,
> PREDNISONE, AND THEOPHYLLINE.]{.smallcaps}
>
> [ASTHMA CONTROLLERS: CROMOLYN, FLUTICASONE, MONTELUKAST, PREDNISOLONE,
> PREDNISONE, SALMETEROL, AND ZAFIRLUKAST.]{.smallcaps}
>
> [ASTHMA INHALED STEROIDS: BECLOMETHASONE, BUDESONIDE, FLUNISOLIDE,
> FLUTACASONE, FLUTICASONE/SALMETEROL, AND ZAFIRLUKAST..]{.smallcaps}

8.  **Fourth tier:** Rosebud Comprehensive Health Care Facility
    Activities utilizes a 3-layer system for the clinical management of
    childhood asthma. On-site "telemedicine" pulmonology consultation
    (an audio stethoscope), utilizing a pediatric pulmonologist and an
    adult pulmonologist. Reports of consultation are aggregated by the
    telemedicine coordinators that transact the videoconference-based
    consultations, passed to the RT-asthma case manager who interacts
    with the primary care provider to effect actionable items. Neither
    patient nor consultant has to travel.

9.  What research is needed? Response: Dr. Teramoto suggested research
    on systems of care for asthma in the IHS, access to care models need
    to be better understood.

10. The final layer: aggregates clinical management assessment reports
    that are produced by the case manager and presented to the medical
    staff as a performance improvement initiative.

Thanks for the great discussion and information.

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