CLINICAL NURSE LPN, RN, BSN,

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Comprehensive asthma care often requires a team of health professionals, each with specific skills and experience in asthma diagnosis, treatment, patient education and counseling.

Benefits of Team Care

A multi-disciplinary team of asthma care professionals can provide multiple therapeutic interventions. The relationship among the health care providers allows for collaborative patient care. This process offers a greater opportunity to satisfy the goals of therapy that are outlined in the Guidelines for the Diagnosis and Treatment of Asthma, developed by the National Asthma Education and Prevention Program (NAEPP) of the National Heart, Lung and Blood Institute (NHLBI).1-6

Inherent to the process is improved communication among the caregivers, themselves, as well as with patients and family members. Patients will recognize the cooperative effort and feel supported, connected and well treated. The comprehensive services of a team promote a continuance of care and an enhanced opportunity for successful patient outcomes.

Benefits include:

• Decreased morbidity and mortality • Reduction in hospitalizations

• Decreased emergency department visits • Decreased unscheduled physician visits

• Decreased side effects from asthma medications • Decreased interference with daily activities • Cost savings

• Increased patient knowledge of asthma care • Increased patient satisfaction

1. Gaioni SJ, Korenblat-Hanin MT, Fisher DB, Korenblat PE. Treatment Outcome in an Outpatient Asthma Center: Retrospective Questionnaire Data. Am J Man Care 1996;2:999-1008.

2. Weiss KB, Gergen PJ, Hodgson TA. An economic evaluation of asthma in the United States. N Engl J Med 1992;326:862-866. 3. Mayo PH, Richman J, Harris HW. Results of a program to reduce admissions for adult asthma. Ann Intern Med 1990;112:864-871. 4. Mason RJ, Time out for asthma. Ann Allergy 1989;63:366-368.

5. Mason RJ, Datz JL, Bethel RA, Time out for asthma: Rationale for a comprehensive evaluation. Sem Respir Crit Care Med 1994;15:97-105.

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Team Members

The composition of an asthma care team will vary, depending on the needs of the patient, the clinical set-ting and the specific training and experience of the team members. However, an asthma care team typical-ly will be a combination of these health professionals:

Allergist

Asthma Educator

Certified Pulmonary Function Technologists (CPFT) Certified Respiratory Therapist (CRT)

Licensed Practical Nurse

Medical Assistant / Medical Technician Nurse Practitioner Nutritionist Otolaryngologist Pastoral Care Pharmacist Physical Therapist Primary Care Specialist Psychosocial Therapist Pulmonologist

Registered Nurse

Registered Pulmonary Function Technologist (RPFT) Registered Respiratory Therapist (RRT)

Speech Therapist

Others who can be highly important to the asthma care team would have responsibilities in: Marketing

Business Manager/Administrator

In some communities and health care settings, the entire team may be on staff, as in a hospital or medical center. In other situations, a community-wide network of professionals may provide the pool from which patient-specific teams can be assembled.

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Team Member Skills and Roles

All members of the asthma care team must be knowledgeable about asthma and other allergic diseases. Specifically they should know the principles of the Guidelines for the Diagnosis and Treatment of Asthma, developed by the National Asthma Education and Prevention Program (NAEPP) of the National Heart, Lung and Blood Institute (NHLBI).

Each team member has responsibilities in asthma education.

In addition to the physicians, there are certain health care personnel who are the core of an asthma care team. The qualifications and the range of roles for each are outlined below.

CLINICAL NURSE – LPN, RN, BSN, or MSN

1. Acts as a primary liaison between the patient, the physician and ancillary services.

• Coordinates scheduling of procedures and tests with physicians, patients and other ancillary staff. • Prepares patients for physician examination.

• Takes vital signs and auscultates the chest. Collects blood and urine samples for testing, performs spirometry, EKGs, performs skin tests and assists physicians in reading those tests.

• Performs immunotherapy and immunization injections. • Performs and instructs patients in aerosol therapies.

• Assists in code emergencies and must be CPR-certified and have knowledge of a crash cart. • Handles triage for incoming phone calls regarding patient care and treatment, and provides general

information about asthma therapy and patient self-care. • Provides individual case management.

2. Uses professional judgment as the basis for decisions affecting patients. • Assesses, plans, implements and evaluates the patient’s care.

• Administers medication to patients when prescribed.

• Has skills in the use of inhaled medication and lung function tests. 3. Develops and implements age-appropriate asthma education.

• Provides individual and group education on topics such as medication administration, environmental controls, peak flow monitoring and crisis planning.

• Gives talks to patient groups and provides health education articles for newsletters and other publica-tions.

• Promotes community education through programs such as health fairs, asthma screening, asthma camps and school-based education programs.

4. Develops and solves problems pertaining to standards of care and protocols. • Creates and provides in-service education for the hospital staff, and office staff. • Develops, initiates and implements asthma care path protocols.

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PULMONARY FUNCTION TECHNICIAN – Registered/Certified Pulmonary Function Technologist (RPFT or CPFT ), and/or Registered/Certified Respiratory Therapist (RRT or CRT)

1. Prepares, calibrates and maintains equipment.

2. Performs or instructs patients in various tests and procedures.

• Performs spirometry, plethysmography, DLCO, exercise stress tests, bronchial provocation, oximetry at rest and exercise, and nitrogen washout.

• Performs peak flow, FEV1and FVC screening procedures.

• Draws arterial and venous blood gas samples and performs other duties as required. • Takes vital signs and auscultates the chest.

• Performs aerosol therapy.

• Develops instructional materials pertaining to oral medications, actions plans and asthma manage-ment tools such as peak flow meter, metered dose inhaler and holding chamber.

3. Develops and implements age-appropriate asthma education programs.

• Provides individual and group education on topics such as medication administration, environmental controls, peak flow monitoring and crisis planning.

• Gives talks to patient groups and provides health education articles for newsletters and other health publications.

• Promotes community education through programs such as health fairs, asthma screening, asthma camps and school-based education programs.

4. Assists in code emergencies and must be CPR-certified and have knowledge of crash cart.

MEDICAL TECHNICIAN

1. Prepares patients for physician examination.

2. Performs skin tests, peak flow measurements, allergy injections and immunizations, stat tests and vari-ous other

laboratory tests.

3. Assists in code emergencies and must be CPR-certified and have knowledge of crash cart.

PHYSICAL THERAPIST – PT

1. Outlines procedures for the evaluation and treatment of physical therapy patients.

• Reviews patient history and performs and assesses an ADL (activities of daily living) index. • Measures vital signs.

• Assesses auscultate breathe sounds, breathing patterns, chest mobility, range of motion, strength, muscle endurance, posture, imbalance and gait. Measures rib angle and chest expansion at axilla and mid-sternum.

• Performs exercise testing such as walk and stair climb, stress tests, heart beat and blood pressure. • Establishes patient home exercise programs for strengthening, range of motion, endurance, posture,

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the benefits of endurance exercise.

2. Coordinates with available pulmonary rehabilitation programs.

ASTHMA EDUCATOR – RN, MSN, NP, RRT, CRT, MSW or ALA-certified or other Asthma Educator

1. Educates patients.

• Develops, writes, edits and monitors asthma education programs and manuals directed to adults, teens, children and parents.

• Markets the education program to the community, patients and family members, physicians, insurers and

managed care administrators.

• Coordinates and organizes the dates, locations and facilitators for patient education sessions. • Coordinates with inpatient, outpatient and community asthma programs and resource groups. 2. Coordinates adult and pediatric support groups.

• Coordinates programs, locations and dates.

• Recruits patients who could benefit from participation in group. • Designs group structure, content and materials.

• Finds financial support.

• Coordinates with inpatient, outpatient and community asthma programs and resource groups. • Markets the groups to the community, patients, insurers and managed care administrators. 3. Conducts community outreach.

• Coordinates health fairs, asthma screening programs and other health education programs.

• Gives talks to patient groups and provides health education articles for newsletters and other health publications.

• Gives presentations to health care professionals, schools, corporation employee programs, inpatient and

outpatient facilities and other organizations requesting assistance. 4. Conducts psychosocial research.

• Organizes and conducts asthma-related quality of life, patient satisfaction and other psychosocial research.

• Incorporates quality improvement process with outcomes research.

SOCIAL SERVICES/PSYCHOSOCIAL INTERVENTION – MSW, LCSW or PhD in Psychology

1. Educates patients.

• Assists in the development and implementation of asthma education for adults, teens, children and parents.

• Conducts asthma education sessions on coping techniques.

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• Provides psychosocial in-service training for staff at inpatient, outpatient and community-based facilities. • Provides an active and experiential learning process.

2. Provides social services.

• Develops psychosocial assessment guidelines and psychosocial history forms.

• Conducts psychosocial initial interviews with all new asthma patients to determine the functional status of the patient and the impact of the disease on the patient and the patient’s family.

• Provides individual, marital, family and group therapy. • Develops psychosocial treatment and discharge plans. • Establishes a psychosocial community resource network.

3. Coordinates and conducts adult, teen, pediatric and parent asthma support groups. 4. Conducts community outreach.

• Provides articles on asthma to newsletters, magazines and other publications.

• Gives presentations on the psychosocial dimensions of asthma to health care professionals, schools and other

organizations requesting assistance. 5. Conducts psychosocial research.

Education Psychosoci al therapy Pulmonary rehabilita-tion Physical Therapy Pulmonary function pro-cedures Speech therapy Vocal chord x x xx dysfunction Steroid x x x x x dependence Chronic x x cough Poor x x x control Obstructive x x x x lung disease Restrictive x x x x lung disease Allergy x x Psychosocial x x dysfunction Physical x disability High risk x x x Sinusitis x Prone

Intervention

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• Organizes and conducts asthma-related quality of life, patient satisfaction and psychosocial research. • Assumes a leadership role in the publication of psychosocial research.

The table below shows specific conditions that may require intervention by particular members of the asth-ma care team.am Care Implementation

The steps for implementing asthma team care vary with the clinical settings and communities. Presented below are example strategies for creating and maintaining comprehensive team care in three different set-tings.

INPATIENT FACILITY

1. Designate staff to lead the asthma team care process.

2. Assemble the asthma care team with representation from appropriate departments such as Allergy, Pulmonary, Respiratory, Nursing, Social Work, Emergency, Pharmacy, Pastoral Care, Marketing and Administration.

3. Develop the team goals, mission, structure and operational strategy.

4. Establish emergency room and inpatient care paths (described elsewhere in this Asthma Disease Management Resource Manual).

5. Develop and implement asthma education and support group programs for hospital and medical center staff, patients and their families.

6. Provide programs and resources to outpatient medical facilities and the community at large. 7. Coordinate the team care process with outpatient specialists and primary care physicians. 8. Establish outcome studies and quality improvement guidelines that evaluate:

Cost effectiveness

Utilization of inpatient resources Patient satisfaction

Quality of life issues Medical outcomes

9. Establish a schedule of periodic meetings of the team to sustain the process.

PRIMARY CARE SPECIALIST OUTPATIENT FACILITY

1. Designate staff to lead the asthma team care process. 2. Identify and assemble the asthma care resources:

Educational opportunities Support groups

Psychosocial community referrals Pulmonary function laboratory

Allergist/Pulmonologist/ENT referral sources Pulmonary rehabilitation programs

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Community organizations, including information about their locations, accessibility and third-party reimbursement. Organizations may include:

• American College of Allergy, Asthma & Immunology • American Academy of Allergy, Asthma & Immunology • American Lung Association

• Asthma and Allergy Foundation of America • Allergy & Asthma Network/Mothers of Asthmatics • Food Allergy Network

• Immune Deficiency Foundation

3. Establish a collaborative consultation relationship with an asthma specialist. 4. Provide in-service training on the asthma team approach for office staff. 5. Create guidelines, forms and referral sheets. Devise easy access locations. 6. Conduct quality assurance to ensure the process is maintained.

7. Establish a database of all patients with asthma. 8. Provide ongoing asthma education programs for staff.

9. Participate in the inpatient or medical center asthma care team.

ASTHMA SPECIALIST OUTPATIENT FACILITY

1. Create an inventory of asthma resources: Education and support group programs Psychosocial community referrals Pulmonary function laboratory Other respiratory medical specialists ENT specialist

Pulmonary rehabilitation Speech therapist Nutritionist

Rhinolaryngoscopy equipment

2. Provide collaborative consultation for primary care physicians. 3. Participate as a member of the inpatient asthma care team.

4. Participate in managed care committees (i.e., quality of care, formulary).

In conclusion, the steps for implementing asthma team care vary with the clinical settings and communi-ties.

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