An Editorial Webinar Presented by

ADVANCE for Respiratory Care & Sleep Medicine and the Merck Childhood Asthma Network, Inc.

April 13, 2011

Today’s Agenda and Speakers

The Challenges of Childhood Asthma Dr. Floyd Malveaux, Merck Childhood Asthma Network, Inc.

Early Insights from the HEAL Phase II Project Dr. Leonard Jack, Xavier University

Lessons Learned from the Community Asthma Prevention Program Dr. Tyra Bryant-Stephens, Children’s Hospital of Philadelphia

Managing Childhood Asthma in the School System Yolanda Cuevas, Los Angeles Unified School District

Q&A

The Challenges of Childhood Asthma

Floyd J. Malveaux, M.D., Ph.D.Executive Director

Merck Childhood Asthma Network, Inc.(202) 326-5200

floyd_malveaux@merck.com

• The Merck Childhood Asthma Network, Inc. (MCAN) is a nonprofit organization [501(c)(3)] founded in 2005 and funded by The Merck Company Foundation

• Mission: To enhance the quality of life for children with asthma and their families, and to reduce the burden of the disease on them and society

MCAN Aims to Make a Difference in the Lives of Millions of Children with Asthma

Improve access to and quality of healthcare for children, especially the vulnerable and medically

underserved

Advocate for policies that expedite dissemination, implementation and sustainability of science-based

asthma care

Increase awareness and knowledge of asthma and quality asthma care

Childhood Asthma is Challenging on Many Levels

• 1 in 7 ever diagnosed• 9% currently have it• 60% have had at least one attack in the

past year

Widespread and Serious

• $8-10 billion in medical expenditures (’10)• Additional $10 billion in indirect costs• 40% higher emergency department costs

Costly

Preventable and Avoidable

Overcoming Asthma Requires More Than Just the Right Medical Care

• We know enough about asthma to do better in controlling its symptoms: assure better access to quality, affordable care, and implement/sustain efficacious science-based programs

• Bring together the right people, programs and policies in ways that remove barriers and promote enhancers for better asthma management and care

• Document and share the results of implementation research and the approaches that are most effective, and then work to sustain the changes

Current Research Definitions Central to Systemic Change, Quality Care

“…the study of how a specific set of activities and designed strategies effect the integration of evidence-based information and interventions

“into health care and community health practices”

Vol. 6, No. 6, November/December 2008

Implementation Research is…

Basic Research

Human Research

Practice-Based

ResearchPracticeT T T=QI

Not ready for humans

Not ready for patients

Not ready for practice

Cells Practices

Biochem

istry

Cells/Tissues

Exp. Anim

als

Phase I Trials

Phase II Trials

Phase III Trials

Meta-analysis

Guidelines

Implem

entation D

issemination

Phase IV TrialsC

ost-effectiveness

Best Practices

TrainingFacilitationR

e-engineering

What’s possible?

Can it work?

Will it work? Is it worth it?

Translational Research –Continuum from Bench to Practice

Diseases People

Implementation Research: Important Asthma Outcomes

Translation/Implementation of results from randomized clinical trials (RCT) into routine clinical practice and

public-health decision making helps:

• Ensure access to high quality health care• Implement evidence-based guidelines and interventions• Coordinate “systems” of care (clinical, social, school,

etc.)• Improve communication - providers, patients, families• Address environmental issues that impact health• Encourage healthy behavior to reduce risk/enhance QOL

Evidence-based interventions (EBI) deemed efficacious

within clinical or community-based trials

are often multi-level interventions and are not easily translated into routine practice

Interventions Often Multi-Level

Interventions Often Multi-Level

Context is important and EBI are rarely

transferable without adaptations to specific settings; partnerships

and varied approaches are

essential

Variety and Adaptation Important

Variety and Adaptation Important

Implementation research should

address the level to which health

interventions can be integrated into real- world public health and clinical service

delivery systems

Should Address Real World

Should Address Real World

Implementation Research Has Taught Us Important Lessons

Early Insights from the Head-Off Environmental Asthma in Louisiana

(HEAL) Phase II Project

Leonard Jack, Jr., Ph.D., MSc.Lead Investigator, HEAL Phase II Program

Director, Center for Minority Health & Health Disparities Research and EducationXavier University(504) 520-5345ljack@xula.edu

HEAL Phase II Hopes to Improve Health Outcomes by Expanding on Phase I Lessons

HEAL I included multifaceted approach: • Asthma counselor intervention (National Cooperative Inner City

Asthma Study)• Environmental intervention (Inner City Asthma Study)

HEAL II will:• Extend and build upon the lessons learned from HEAL Phase I• Improve pediatric asthma management in Greater New Orleans

area• Examine those aspects of the HEAL II intervention that have the

greatest impact on outcomes

Collaboration Key to HEAL II Success

Xavier University College of Pharmacy Center for Minority Health and Health

Disparities Research and Education

Merck Childhood Asthma Network

(MCAN)

Daughters of Charity

New Orleans (DCSNO)

HEAL to Integrate Best Practices into Existing Structure at Daughters of Charity New Orleans

Patient’s Desires& Needs

PatientPanels

Outcome and

ResultsMeasures

PopulationRegistries

Open Access

Team Based Care

MDNurse CM

CMAPt Care Coord

Behavioral Health

Consultant

ImmediateImmediate

PROACTIVE TREATMENT

Project Collaboratives

PATIENT CENTRIC SERVICES

Continuous Quality Improvement

Continuous Quality Improvement

Engaging Stakeholders Early in the Process is Key to Informing Program, Improving Outcomes

Building Trust, Tapping into Existing Resources Present Opportunities, Challenges

• Intervention fidelity

• Evaluation: “What is Success?”

• Building upon mutual interests and strengths

• New partnerships require time to establish and maintain trust

Outcomes, Evaluation Protocol Should be Key Factors in Each Stage of Program

Data Collection and Evaluation• Evaluate change in health status/health outcomes–Program Evaluation Outcomes: “What are the right data?”

Program Outcomes to Evaluate Health Systems• Patient –Quality of Life–Asthma Self-Efficacy–Patient Satisfaction–Symptom Monitoring • Providers–Implementation of NAEPP-EPR3–Training Satisfaction

Programs Should be Sustainable and Best Practices Easy to Institutionalize

Electronic Medical Records• Decision Support Tool• Utilize Electronic Asthma Action Plan

Clinical Outcomes• Peak Flow • Lung Function

Program Sustainability• Participation Rates • Attrition Rates• Capacity to Deliver Intervention

Lessons Learned from the Community Asthma Prevention Program (CAPP)

Tyra Bryant-Stephens, M.D.Director and Founder, Community Asthma Prevention Program

The Children’s Hospital of PhiladelphiaClinical Associate Professor of Pediatrics, The University of Pennsylvania School of Medicine

(215) 590-5020stephenst@email.chop.edu

CAPP Has a Long History of Helping Philadelphia Children with Asthma

• Founded in 1997

• Premise: Despite medical advancements, children in West Philadelphia urban primary care practice continued to go to the ED and hospital for asthma exacerbations

• Clearly a gap existed between medical management and self-management behavior

19971998

1999

2000 2001 2002

2003 2004 2005 2006 2007 2008 2009 2010

CAPP

is founded by Dr. T. Bryant-

Stephens

in response to high prevalence of asthma ED visits.

strategies include community education,, and training community leaders

Home Visits added.Classes and and Train-the-Trainer are implemented

Community Advisory Board established

CAPP expands Home Visits

program in West. South, & Southwest Philadelphia (EPA).

CAPP Collaborative

is formed. The four-prong approach

includes: Home Visits, Community Classes, PCP Training, and School Interventions.

Merck Childhood Asthma NetworkFunds school, home and community interventions

Smoking CessaitionCounseling added to CAPP.

Controlling Asthma in AmericanCities project implemented over five years

CAPP receives NIEHS EJ award for West Philadelphia

Door-to-door and school screenings

MCAN funds Asthma Health Navigator Program

• Identified stakeholders through colleagues, community agency lists, residents and word-of-mouth

• PI and Study Coordinator met individually with stakeholders• Started at ground zero

– Do you think asthma is a problem in your community?– How much of a problem?– Are there resources already present?– What else would you like to see?

• Worked through our community relations department to identify other organizations

• Started making cold calls to community-based orgs (CBOs), faith-based orgs (FBOs) and other stakeholders

Making Community Connections is Key to Program Success

Multiple Benefits of Getting the Community Involved in Solving the Asthma Problem

• Involve community agencies who are already working at a grassroots level in the planning

• Be flexible in meeting times for meeting with people who live in the community

• Go to the leaders of the CBOs, admit your ignorance

• Ask what? How? Where?• Answer for the CBOs why?

Reaching the Community Where they Live, Work and Play is an Important First Step

• Used local papers• Distributed flyers to all community

sites• Offered an asthma education class

to the staff of different community sites in exchange for hosting a class

• Removed barriers such as transportation, childcare, classes held at evening hours

CAPP Ensures Longevity by Equipping the Community with Asthma Educators

• Train parents who are highly motivated and attend your classes to teach the classes

• Hire lay educators from the community • Believe in “word of mouth”• Respect targeted population’s cultural beliefs

and practices. Incorporate into your curriculum.

Healthcare Providers Can be Important Partners in Community Programs

• Ask for permission to share families participation with your program

• Send letters to PCPs• Offer to come (bring lunch) and talk about

your program• Allow PCPs to refer through website/fax• Leave information flyers in their offices

Establishing a Trusting Relationship is Key

• Allowed the community to be the experts

• Admit our ignorance about the pressures they have which exist outside our area of research (e.g., undocumentation, cultural differences)

• Ongoing conversations and clarification of what everyone needed

• Were honest about what each stakeholder needed from the partnership – asked the hard questions at the beginning – created MOUs

• Flexibility - Protocol amendments made as needed

Keeping Partners Engaged is an Important Element of a Successful Program

• Leadership meetings on a monthly basis

• Monthly team implementation meetings where all stakeholders involved attended

• Collaborative, CAB, or project meetings on a quarterly basis

• For subcontractors in the beginning checked in via phone or email on a weekly basis

Determine Protocol for Working with Partners to Ensure Adequate Research Methods

• Establish parameters for technical assistance from the research team

• Had comprehensive training and orientation process;

• Central supervision of research methodology and data collection

– Daily calls to supervisor with schedules

• Monthly meetings with all field workers; reviewing data forms each month

• Data QA meetings quarterly

• Expect and Inspect

Programs that Keep the Community Involved Long-Term Are Most Successful

• Let the community have final approval of project• Insist upon a true partnership• Create opportunities for ownership of the project

(e.g., C.A.B., steering committee)• Have interactive meetings• Give opportunities for anonymous feedback about the

project• Stamp out fires quickly and directly

CAPP’s Success is Based on Implementing a 360 Approach to Community Programs

• Highly effective partnerships• Collaborative model: Two-way

partnership• Utilization of community residents

as experts in design of research and frontline implementers

• Rigorous training of community health workers

• Commitment to leave the community better equipped to manage asthma

Managing Childhood Asthma in the School System

Los Angeles Unified School District Nursing Services Asthma Program

Yolanda Cuevas, RN, BSN, MAed, PHN, RCPProgram Manager and Credentialed School Nurse

Los Angeles Unified School District’s Nursing Services Asthma Program(213) 765-2809

Yolanda.cuevas@lausd.net

The Mission of the LAUSD Nursing Services Asthma Program is to improve the health and academic achievement of students with asthma by reducing asthma exacerbations through the education of

students, parents and staff on the prevention and management of asthma.

Implementing an Asthma Program in LAUSD Challenging but Necessary

• 2nd largest school district in the nation

• A diverse, urban student population– 74% Hispanic;

11% African American– ~80% eligible for

school meal program• An estimated 77,000

students with asthma

LAUSD Nursing Services Program Targets High-Risk Children at Home and School

• Case management for students who are at high risk for negative health and academic outcomes

• Asthma education in the home and at school

• Mitigation supplies to reduce in home asthma triggers

LAUSD Asthma Program is Unique and Multi-Faceted

• School-centered• School Nurses (RN and

credentialed) provide:– Home visits– Asthma education (individual)– Case management

• School-based asthma education classes (Open Airways [OAS], Fight Asthma Now [FAN])

• Coordination with medical providers (Breathmobile®, community clinics, hospitals)

LAUSD Asthma Program Managed More Than 1,000 Students Over Four Years

Demographics of Participants

71% Hispanic/Latino22% African American (11% of the District)

Outcomes of Participants

Improvement in symptomsDecreased ER visits Increase in appropriate use of asthma medicationIncreased use of an asthma action plan Decline in missed days of school: 14 to 5 days/year

Opportunities and Challenges to Running a School-Based Asthma Program

• Limited school calendar for school nurses to provide services (breaks, furloughs, etc)

• Priority on school campus is education and academics (mandatory testing dates)

• Families have other pressing priorities that decrease compliance

• Medical providers have limited knowledge, skills and motivation (reimbursement) to provide:– Asthma Action Plan– Spirometry– Peak Flow- instructions, equipment

Using Existing Resources, Leveraging Relationships Key to Success of Program

• Using resources within the school, including key personnel:– School Administrators– Pupil Attendance Counselors – School Nurses– Teachers

• School nurse access to students and their records• Built-in trust with parents, and it is where the

students are (90% U.S. students attend a public school)

Schools Provide Important Opportunities for Collaboration to Tackle Asthma

• School personnel – nurses, administrators, teachers• School-based asthma educational programs: OAS and

Kickin’ Asthma, Fight Asthma Now • Indoor Air Quality Improvement – EPA’s Tools for

Schools Program• Local Asthma Coalitions often include educational

agencies• Community clinics, health systems or health plans may

offer provider education (e.g., Physician Asthma Care Education [PACE])

• AAFA and other non-profits sponsor mobile asthma vans (Breathmobile®)

Q&A

Floyd J. Malveaux, M.D., Ph.D.Merck Childhood Asthma Network, Inc.

(202) 326-5200floyd_malveaux@merck.com

Leonard Jack, Jr., Ph.D., MSc.Xavier University(504) 520-5345ljack@xula.edu

Tyra Bryant-Stephens, M.D.The Children’s Hospital of Philadelphia

(215) 590-5020stephenst@email.chop.edu

Yolanda Cuevas, RN, BSN, MAed, PHN, RCPLAUSD Nursing Services Asthma Program

(213) 765-2809Yolanda.cuevas@lausd.net

An Editorial Webinar Presented by

ADVANCE for Respiratory Care & Sleep Medicine and the Merck Childhood Asthma Network, Inc.

April 13, 2011