The statistics on asthma are staggering. More than 17 million Americans are affected by the disease, according to the National Institute of Allergy and Infectious Disease. Of these, nearly 500,000 are hospitalized each year for asthma-related complications. Across the country, health care providers are looking to education in order to reduce the incidence of asthma attacks, thus reducing the cost of emergency department visits and hospitalizations.
In Virginia, one health system has devised a creative solution for accessing at-risk children and teaching them how to manage their asthma. Chesapeake-based Sentara Home Care Services, a division of Sentara Healthcare, uses telemonitoring to teach middle-school children about their asthma, triggers they should avoid and proper use of their medication and equipment.
The company's TeleCoach asthma program utilizes a remote telemonitoring station dressed up like a coach to connect children at the Hunt-Mapp Middle School in Portsmouth, Va., to home care nurses in the Sentara office. The interactive system has two-way live audiovisual capabilities that enable the nurses to listen to the students' lungs while educating them about seasonal asthma triggers and solutions.
The goal of the program, says Rhonda Chetney, RN, MS, director of clinical operations for SHCS and one of the creators of the TeleCoach program, is to keep kids in school — and out of the hospital.
CREATING THE SOLUTION
The company recognized that a number of children — who were difficult to follow due to their families' frequently changing contact information — were being referred to its existing childhood asthma program. Chetney and her staff knew that one-on-one contact would be the most productive way to educate these children and their parents, but the traditional method of calling for appointments, even showing up at their homes on weekends and evenings, was not working.
So Chetney looked to Sentara's Cardiac Connection program — which uses video telemonitoring to provide comprehensive home care to patients with congestive heart failure — to develop a telemonitoring concept that would work for children with asthma. Further, the team developed a plan to connect with the at-risk children in a place where they are easily located: school.
“We have had a child asthma program since 1997 that involves our nurses going into the children's homes and visiting with them, which we call our LifeCoach program,” explains Chetney. “At the same time, Sentara had a telehealth program for cardiac patients. So, we decided to take the two and combine them and also partner with the schools, because that is where the kids can be found.”
Education is a positive element of asthma management, even when it takes a non-traditional slant such as with the TeleCoach program. Scott Bartow, director of HME for SHCS, says it serves two purposes.
“It is good for people. Although home medical equipment providers run the gamut, my belief is that, in essence, that industry was developed by … respiratory therapists. You have people with a clinical orientation who truly want to see the patient improve,” he explains.
“The other reason for having an asthma disease management program is because it ties you in with your referral sources, and that's what can help any organization distinguish itself from its competition as we all struggle to get our share of the pie, so to speak,” Bartow elaborates. “Here is an opportunity to demonstrate a difference between you and a competitor and to build a relationship with the medical community. It demonstrates that you help their patients; you're interested in them.”
To make the TeleCoach program successful, Chetney and her staff had to determine which school would benefit the most, and how to persuade the school staff to accommodate the program. After analyzing the cities in their service area that had the highest incidence of childhood asthma, one that really stood out was Portsmouth, especially when the team discovered there was a middle school in the district that had more than 200 students with the condition.
Once the pilot school was chosen, the program had other challenges. The school nurse was hesitant, and students had to be convinced to sign up for the TeleCoach sessions. However, the students were quick to participate once they saw the “coach.” And when the school nursing staff realized the program would reduce their workload and increase the students' attendance, they also bought into the program and its benefits.
“It is all tied together with keeping the kids in school,” says Chetney. “If we can keep these kids healthier, they will be in school, in class and will do better.”
According to Chetney, the students' interest was enthusiastic. “We parked that crazy-looking thing in the school nurse's office and put a sign-up board next to it. Within a week, we had 18 kids signed up,” says Chetney.
Each student that signed up needed parental consent for the program. Chetney says this is a positive factor, because the goal is to gain access to the home environment. “We still try really hard to get into the home because there are so many triggers for asthma in a child's home,” she explains. “It is one thing to teach them about it, but it is more successful if we can get in front of the parents by getting our foot in the door through the school.”
Asthma triggers do not always have to be complicated. Often, they are common pollutants. However, for someone with asthma, they can be threatening. The most common include second-hand cigarette smoke, dust mites, chalk dust, outdoor air pollution, cockroach allergies, pet dander, mold, strenuous physical exercise and cold air or high humidity. The TeleCoach program focuses on triggers and offers the children real-life solutions for handling them.
The good news about the TeleCoach program in Portsmouth is that it is able to affect these students at an optimum time. “There is some literature that has shown that if you can impact kids at [the middle-school age] who have certain kinds of chronic diseases, you can make a difference in their whole life down the road,” says Chetney.
She emphasizes the global effects of a program like TeleCoach: When the students are encouraged to become more active, they develop an attitude that demonstrates self-care and, thus, take better care of themselves. This is especially true when an accountability factor is involved, Chetney says. “When they know somebody is looking at them every week and somebody is paying attention, they begin to take better care of themselves.”
Often, at-risk children face parental resistance to reducing asthma triggers, such as exposing the child to second-hand smoke. Sentara's nurses can offer immediate suggestions and also provide supportive measures.
“The nurses really spend a lot of time talking to [the children] about these kinds of things, because with some kids, any kind of emotional stress can be a trigger for them,” explains Chetney. “Plus, we also know that if the home is not conducive to a child's being able to live there with his asthma, then we really need to get in there. If this is brought up during a session or if the nurse tries to score some of that information, then she tries to schedule another home visit and get out to the home.”
Additionally, the program offers an incentive plan. The nurses play the “asthma trigger game” with students, which involves collecting asthma trigger cards that the child receives when he attends his scheduled meeting with the TeleCoach. At the end of the school year, the students receive incentive prizes based on the number of the cards they have collected.
“At the end of the school year, they can turn in their collection of the trigger cards and receive rewards,” says Chetney, “so the more cards you have, the more compliant you were and you can get prizes. We focus on a sports theme, so they can get all kinds of prizes, such as basketballs or gym bags.” The program offers prizes for keeping appointments as well.
“We had pencils made up with the common triggers printed on them,” explains Chetney. “When the students use the pencils in school, they can look at them and remember what they have learned about their asthma.”
Pulling the TeleCoach program together involved creativity and commitment. The head and sneakers were donated, and Chetney purchased the sweat suit at a discount store. She says the main thing to remember is that TeleCoach is a tool. “It's a tool for clinicians to use to help improve the patient's health status,” she says. “The main thing is to have the clinician behind the tool.”
FOCUSING ON EDUCATION
According to Bartow, the more information that is shared about asthma, its triggers and its dangers, the better the outcome for patients. That is why he appreciates the TeleCoach program and the opportunities it offers Sentara's home care services and HME operations.
“Asthma is still one of those diseases that has a wealth of information and appropriate protocol to treat, and yet, the population is by-and-large underserved in terms of getting that help,” says Bartow. “Because we have different [types of] patients, we see people who are underserved and can refer them over to the program.”
While Bartow is on the equipment side — and stresses that its proper use is a key component of any effective asthma management regimen — he provides a global view of the TeleCoach program.
“The equipment part is one component, but proper use of the medications, staying away from the triggers and lifestyle changes are all tied in with a good program,” he says.
He emphasizes that proper use of the equipment — whether it is a metered dose inhaler or a nebulizer — is critical to the students' good outcomes. “If the equipment is not used properly, they do not get the benefit of the medication. Therefore, a key component in any asthma program is the proper use of the equipment,” he states.
RAISING THE BAR
Sentara's TeleCoach program has been extremely successful. The students at Hunt-Mapp Middle School who participated in the program reduced missed school days by 61 percent, decreased emergency department visits by 70 percent and decreased hospital admissions by 86 percent. Overall school attendance for the students also has improved, though it is a more difficult statistic to verify.
Currently, SHCS provides up to 200 personalized televisits per year when students stop by the school nurse's office to use their inhalers just before their physical education class once a week. The program is now being offered to any student with asthma at Hunt-Mapp Middle School, and plans are to expand the program to additional middle and elementary schools in the region. In fact, Chetney hopes Sentara's innovative approach to asthma disease management for school-aged kids will be mimicked across the U.S.
“Children all over the country can benefit from this kind of program. It doesn't cost that much to do something like this, and the benefits are great,” she says. “You just have to be a little bit creative and say, ‘Hey, let's go for it. Something crazy like this might work.’”
TELECOACH SCORES HIGH MARKS
The success of Sentara's TeleCoach program shows in its results for students with asthma at Hunt-Mapp Middle School. The program has:
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Reduced missed school days by 61 percent
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Decreased emergency room visits by 70 percent
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Decreased hospital admissions by 86 percent
