Pediatric Asthma in Rural Wisconsin: Guleed

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Pediatric Asthma in Rural Wisconsin Guleeds
Journey

• Clarion Interprofessional Case Competition
• Fall 2006
• Prepared by students from the Medical University
  of South Carolina
• Charleston, South Carolina

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You must be the change you want to see in the
world." Mahatma Gandhi
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Learning Outcomes

• Identify and define contextual variables
• Understand causal relationships between events in
  case
• Elucidate root causes underlying adverse events
• Resolve root causes with specific recommendations
• Justify recommendations with cost analysis

• Prevent recurrence of event

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Contextual Variables
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Contextual Variables

• Geography

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Corlett County, Wisconsin
Pasco Community and Pasco Satellite Clinic of
River Rapids Hospital
River Rapids Community and Hospital System
10 miles
40 miles
North West East South
Pleasantville Community And Hospital System
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Asthma in Wisconsin

• Approximately 9 of WI residents report being
  diagnosed with asthma 3rd most common chronic
  medical conditionB
• 22,000 hospital ED visits for asthma in 2002,
  average charge 510
• 5,000 hospitalizations for asthma in 2002,
  average charge 7,000
• Total WI asthma hospitalization costs/yr 36
  million
• Children have highest rates of asthma ED visits,
  hospitalizations

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Asthma and Blacks in WI

• Increased prevalence among low-income households,
  adult females, and Black populations
• Twice as likely to be diagnosed, six times more
  likely to be hospitalized for asthma than whites

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Contextual Variables

• Refugee Population

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Somalia

• East African coastal country, population 8.5
  million, 85 nomads or farmers.
• Languages Somali (af Maxaa), Kibajuni,
  Chimwiini, Maymay (Maay), Zizgua
• Predominant Religion Islam
• Cultural Customs
  modesty, oral tradition,
  central role of Muslim
  religion in daily life

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Somali Refugees

• Somalis increasingly seek refuge from their
  devastating civil war to Midwestern US areas
  including Minneapolis-St. Paul, MN Columbus, OH
  Milwaukee, WI
• Culture adjustment, language barriers, living
  conditions, employment, health care, and
  transportation are common difficulties facing
  Somali refugees in the US

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Medical Screening of Refugees

• Section 412 of Refugee Act of 1995 mandates
  medical screening within 30 days of arrival by
  qualified professional
• Purpose identify persons with communicable
  diseases, ensure successful and healthy
  resettlement
• Includes chest x-ray, basic physical exam, PPD,
  dental screen, STD tests, other tests
• Opportunity to refer to appropriate health care
  team member for follow up and treatment is
  provided at screening

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Contextual Variables

• Healthcare

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River Rapids Healthcare System

• Main hospital at River Rapids
• 25 beds 19 Med/Surg 3 Critical Care, 3 OB
• CLIA-certified laboratory
• New Emergency Department (ED) with 2 trauma
  rooms, 2 chemo beds, 4 exam rooms

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Pasco Clinic

• One of the five small rural satellite clinics of
  River Rapids Hospital
• Hours of operation M-W-F 8a.m. 5 p.m.
• Staffing One full time nurse practitioner (NP)
  and one part time physician
• Physicians hours 1200 noon 5pm
• Same physician always works clinic to provide
  continuity of care

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Details of Case and Causal Relationships Between
Events
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Guleed and His Family

• Guleed, 4 y/o male Somali refugee
• Two parents work full-time opposing shifts at
  poultry plant
• 12 extended family members in one household, all
  Somali refugees
• grandparents, parents, 6 m/o brother, aunt,
  uncle, 4 cousins

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Guleeds Asthma

• Guleed diagnosed with asthma at immigration
  physical based on bilateral wheezing and hx of
  chronic cough
• Immigration physician started Guleed on
  montelukast (Singulair) chewable tablets
• Not prescribed rescue inhaler at time of
  immigration

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Guleeds Journey Timeline
Time 0
Month 18
Month 20
Month 19
-Arrives in the United States -Diagnosed with
asthma and info in English
-Taken to ED -Albuterol inhaler -Instructions in
English -Pharmacist called to suggest adding
inhaled steroid

• -Seen in ED 4 times and hospitalized twice
• At last ED visit advised to see an allergist
  given phone plus info in English
• Most recent hospitalization record of ED not sent
  to Pasco clinic

-Forgets inhaler at school -Asthma attack -Taken
to ED via ambulance
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Guleeds sentinel event timeline
Seen by charge nurse and receives albuterol
nebulization. Nurse paged physician
Physician arrived
Arrived in ED
10 mins
0 min
0-10mins
Discharged from hospital
Intubated
Extubated
20 mins
3 Days
3 weeks
Airlifted to Pleasantville Guleeds father
arrived at River Rapids
Medical records located and sent to Pleasantville
Arrived at Pleasantville
60 mins
40 mins
2 Days
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Root Cause Analysis
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Root Cause Analysis

• Three significant root causes emerged
  contributing to the sentinel event
• Communication
• Quality of Care
• Access/ Physical Barriers to healthcare

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Positives of RRHS

• Communication
• System for transfer of copies from ED to clinics
  is in place
• Moving to an electronic system

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Communication
Access/ Px Barriers
Sentinel Event
Quality of Care
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Language Barrier
Intra-Provider Communication
Pasco clinic with no system of checksto ensure
important messages from providers screened/noted
Health Dept. website only in English, limited
info
No translation services, despite
immigrant influx
Records not sent from ED to Pasco Clinic
Asthma education info for parents only in English
Physicians only speak English
Poor transition from paper to EMR
Communication
NP communicates to Guleed, disregarding parents
at clinic
Downstream disconnect Parents not given
adequate info, therefore teacher did not
receive vital info
Inadequate explanation/ documents given on
inhaler use in
Parents not explained importance of allergist
appt no appt made
Provider to Patient Communication
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Specific RecommendationsCommunication
Reduced medical errors due to adequate
information about patient disease states
Reduced communication gap between providers and
patients
Reduced medical costs due to increased patient
compliance
Cost-Neutral Pharmacy In-Service
Interpreting services
Pamphlets
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Specific Recommendations for Communication

• Costs Incurred
• Provider to Patient Various Chronic Disease
  Pamphlets in Somali
• Language Interpreting services
• Costs Neutral
• Intra-Provider Pharmacy In-service
• Costs Savings
• Reduced communication gap between providers and
  patients
• Reduced medical errors due to adequate
  information about patient disease states
• Reduced medical costs due to increased patient
  compliance

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Pharmacy In-service

• Educate medical staff on current pharmacotherapy
  topics
• Schedule requirement of pharmacist monthly,
  bimonthly, or quarterly
• Implement when new guidelines are published
• Research most current literature on topic
• Create an evidence based medicine presentation
  appropriate for interdisciplinary team

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Medical Interpreting

• Title VI of Civil Rights Act of 1964 obligates
  medical caregivers to provide interpretation and
  translation to people with limited English
  proficiency (LEP)
• JCAHO includes adequate language services as
  element of accreditation
• Presence of interpreting service significantly
  increases primary care visits, amount of
  preventative care received

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Medical Interpreting

• Lack of payment for translation services deters
  actual availability
• Average cost for professional interpretation
  234/case (including multiple sessions)
• Telephonic interpreting (e.g. Language Line,
  Pacific Interpreters)
  is a common method
• Cost of telephonic
  interpreting for
  Somali
  2.99-4.87/min

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Medical Interpreting

• Federal government matches state expenditures for
  interpretation services covered by Medicaid or
  SCHIP (Medicare does not cover 2.3 million LEP
  seniors)
• Wisconsin does not participate only covers
  interpreting for deaf or hearing-impaired

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Pamphlets in Somali
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Positives of RRHS

• Quality of Care
• Received inhaler eventually
• Prescribed Singulair

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Communication
Access / Px Barriers
Sentinel Event
Quality of Care
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ED not directly staffed by physicians
Lack of expertise in pediatric care
Poor transition from paper records to EMR
Quality of Care
Inappropriate medication administered
Lack of appropriate counseling from pharmacist
Specialists infrequently available
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Specific RecommendationsQuality of Care
Pediatricians salary is less than family
practitioners

• Cost-Neutral
• Page ED on-call physician for emergent cases
  before pt arrives at hospital

Addition of Pediatrician in replacement of
Family Practitioner
Purchase of Pediatric Crash Cart
Addition of Social Worker
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Specific Recommendations for Quality of Care

• Costs Incurred
• Addition of Pediatrician in replacement of Family
  Practitioner
• Addition of Social Worker
• Purchase of Pediatric Crash Cart
• Costs Neutral
• Page ED call physician for emergent cases before
  pt arrives at hospital
• Costs Savings
• Salary Savings Pediatrician lt Family
  PractitionerA

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Positive of RRHS

• Access/ Physical Barriers
• Facilitation of payment plan for parents by
  Social Worker from Pleasantville
• No physician payment required, only hospital
  charges incurred
• Clinics in the community were staffed with nurse
  practitioner
• Referrals made directly to specialists
• Physician was on call and did respond to ED page
  for help
• Hospital operates 24-hr ED
• ED appropriately staffed by nursing team
• Established protocols for transer of advanced
  cases to tertiary care center
• Hospital has capability to receive helicopter
  admissions

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Communication
Access / Px Barriers
Sentinal Event
Quality of Care
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No communication written or oral upon arrival
about healthcare or health condition
Lack of assistance with health care programs
such as Medicaid Badgercare
No onsite physician in ED
No specialists at RRHS
Access/Physical Barriers
No personal transportation
Ineffective health care payment system
No healthcare benefits provided by plant
Restrictive clinic hours
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Specific RecommendationsAccess to
Healthcare/Physical Barriers
Reduced use of ED and ambulance for
preventable occurrences

• Cost-Neutral
• Information on Medicaid reimbursement
• Community Outreach program
• Update Corlett County website

Heath maintenance seminars
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Specific Recommendations for Access to Health
Care/Physical Barriers

• Costs Incurred
• Heath maintenance seminars
• Costs Neutral
• Information on Medicaid reimbursement
• Community Outreach Program
• Update Corlett County website
• Costs Savings
• Reduce use of ED and ambulance for preventable
  occurrences

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Wisconsin Medicaid

• If you do not have U.S. citizenship, but
  lawfully resided in the United States before
  August 22, 1996, you may be eligible for
  Wisconsin Medicaid if you

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Wisconsin Medicaid

• Were lawfully admitted for permanent residence
• OR
• Are a refugee (a person who flees his/her country
  due to persecution or a well-founded fear of
  persecution because of race, religion,
  nationality, political opinion, or membership in
  a social group)

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Wisconsin Medicaid Transportation

• Ambulance transportation
• coverage for emergency services
• Common carrier or private motor vehicle
• coverage for mileage of recipients car or that
  borrowed from friend

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Community Outreach Program

• Organize River Rapids Community Outreach Program
  (RRCOP) to target refugee population for
  education of healthcare opportunities
• Recruit volunteer peer liaison(s) from Somali
  patient population
• Provide volunteers with basic information about
  healthcare opportunities
• Distribute pamphlets to Somalians to supplement
  oral tradition

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Summary of Specific Recommendations
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Summary of Specific Recommendations

• Stock Somali pamphlets
• Establish interpreter service
• Hire a pediatrician and a medical social worker
• Educate all healthcare workers on common disease
  states
• Acquire pediatric crash cart
• Update Corlett County website on River Rapids
• Advise patients and families on Medicaid
  transportation reimbursement

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Goals of RecommendationsCommunication
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Goals of RecommendationsQuality of Care
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Goals of RecommendationsHealthcare/Physical
Barriers
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Cost Analysis Healthcare Perspective
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• Payers (insurer)
• Purchaser (employers)
• Patient (consumers)
• Providers (institutions)
• Practitioners (clinicians)
• Product producers
• Policy makers

• Financial Outcome
• Functional Outcome
• Service Outcome
• Inputs Process
• Technical Inputs
• Efficiency
• Health Status

• Financial Costs
• Opportunity Costs
• Hassle Costs
• Human Costs
• Time Costs
• Product Costs
• Societal Costs

Adapted from Nauert, Roger, 1996, The quest
for value in health care, Journal of Health Care
Finance, 22(3) 52-61.
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Cost Analysis
-Translation Services-
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Cost Analysis
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Cost Analysis

• Inpatient Costs

• ED Costs

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Cost Analysis
Inpatient Costs
ED Costs
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Cost Analysis Patient Perspective
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• Payers (insurer)
• Purchaser (employers)
• Patient (consumers)
• Providers (institutions)
• Practitioners (clinicians)
• Product producers
• Policy makers

• Financial Outcome
• Functional Outcome
• Service Outcome
• Inputs Process
• Technical Inputs
• Efficiency
• Health Status

• Financial Costs
• Opportunity Costs
• Hassle Costs
• Human Costs
• Time Costs
• Product Costs
• Societal Costs

Adapted from Nauert, Roger, 1996, The quest
for value in health care, Journal of Health Care
Finance, 22(3) 52-61.
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Evidence-Based Medicine

• Study Effect of an asthma outreach program
  (AOP), a team-based, case-management
  intervention, on emergency ward (EW) and hospital
  use on 1-15yo
• Control group received single intensive asthma
  education intervention
• Experimental the AOP group, received same
  initial education but then followed-up by nurse
  during intervention period
• Results Reduced Hospitalizations and ED visitsC
• Conclusion Preventative measures decrease
  hospital and ED costs

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Cost Analysis

• Inpatient

• ED

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AVINGS
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Future Directions

• Implement programs that provide
• Public transportation from rural areas in Corlett
  County to proximal health clinic
• Free rural community health screens every quarter
• Healthcare education on more chronic conditions
  with a wider non-English speaking language base
• Obtain and utilize grants/funding

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Public Health Grants

• Wisconsin Rural Hospital Flexibility Program
  Rural Community Grant
• DHHS Health Resources and Services
  Administration Rural Health Network Development
  Program
• DHHS Office of Rural Health Policy Small Rural
  Hospital Improvement Grant (SHIP)
• DHHS Office of Refugee Resettlement Targeted
  Assistance Grant (TAG)

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Public Health Grants

• Current Grants revenue 18,438
• Current Grants provided (88,093)
• Future Grants obtained
• 25,000 avg amt from WRHFP
• (6,250) less amount matched to WRHFP
• 9,300 amt from SHIP
• TOTAL 28,050 in new funds

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Progress Evaluation

• Six month and one year assessment for
• Number of asthma admits
• Average length of stay
• Proportion of accounts accredited to asthma
  hospitalizations
• Number and monetary amount of interpreting
  services utilized
• Number of new patients enrolled in Medicaid and
  assistance programs
• Implementation of Community outreach program
• Grant applications
• Utilization of chronic disease pamphlets
• Update on efficacy of new paging system rules
• Efficacy of the quarterly health seminars

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Evaluation of Progress
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Evaluation of Progress
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Evaluation of Progress
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Closing Remarks

• Interdisciplinary collaboration can successfully
  improve
•        - cross-professional communication   
     - quality of health care       - improve
  access to healthcareConsequently, such
  healthcare alliances are the key to evoking
  positivechange in healthcare systems, ultimately
  optimizing patient care.

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Never doubt that a small group of thoughtful,
committed citizens can change the world. Indeed,
it is the only thing that ever has.Margaret
Mead
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References

• 1. Demographic Services Center -- Census 2000
  Data Total Population By Race Municipality View.
  State of Wisconsin. Dept. of Administration
• 2. Wisconsin Minority Health Report. Dept. of
  Health and Family Services. Available at
  www.dhfs.wisconsin.gov
• 3. Asthma Mortality and Hospitalization Among
  Children and Young Adults -- United States,
  1980-1993 MMWR 45(17)350-353
• 4. Lehman, Dan Van. Eno, Omar. The Somali
  Bantu-Their History and Culture. The Cultural
  Orientation Resource Center Center for Applied
  Linguistics. Washington DC 2003
• 5. Source for Milwaukee, WI phone interview
  with Joan Samson, Department of Health and Family
  Services, Madison, WI5
• 6. Refugee Health Program information from
  Department of Health and Family Services.
  Available at dhfs_at_wisconsin.gov.
• 7. Asthma Trigger (Somali/English). Childrens
  Hospitals and Clinics of Minnesota.
  Patient/Family Education. Available at
  www.childrensmn.org.7
• 8. Schulte A, Musolf J, Meurer Jr, Cohn JH,
  Kelly KJ. Pediatric asthma case management a
  review of evidence and an experimental study
  design. Journal of Pediatric Nursing. 2004
  Aug19(4)304-10
• 9. Powell, Lisa Pharm.D. Pepper, Michael
  Pharm.D. Reviewing the pharmacy department's drug
  information activities. American Journal of
  Health-System Pharmacy. 57(24)2260-2261,
  December 15, 2000.

76
References

• 10. Title VI of Civil Rights Act of 1964.
• 11. Jacobs EA, Lauderdale DS et al. 2001. J Gen
  Intern Med 16(7)468-474.
• 12. Inadequate access to care among children
  with asthma from Spanish-speaking families Jane
  M. Brotanek MD, MPH, Jill Halterman MD, MPH,
  Peggy Auinger MS, Michael Weitzman MD Journal
  of Health Care for the Poor and Underserved 16
  (2005) 63-73.
• 13. Crash Cart Price http//www.cghsfoundation.c
  om/donate.php accessed 10/29/06
• 14. Wisconsin Medicaid. Wisconsin Department of
  Health and Family Services Available at
  http//dhfs.wisconsin.gov/Medicaid
• 15. Community Impact. The Saint Paul Foundation
  of Minnesota. Available at www.saintpaulfoundatio
  n.org
• 16. Nauert, Roger, 1996, The quest for value in
  health care, Journal of Health Care Finance,
  22(3) 52-61.
• 17. Available online at http//www.ncbi.nlm.nih.
  gov/entrez/query.fcgi?itoolabstractplusdbpubmed
  cmdRetrievedoptabstractpluslist_uids10831004
  
• 18. Nauert, Roger, 1996, The quest for value in
  health care, Journal of Health Care Finance,
  22(3) 52-61.

77
Data Sources for Cost Analysis

• A-Annual Salary from 2006 Wisconsin State Salary
  Survey Report. Available at http//www.payscale.c
  om/research/US/StateWisconsin/Salary/show_all
• B- The Burden of Asthma In WI 2004. Wisconsin
  Department of Health and Family Services.
  Available at http//dhfs.wisconsin.gov
• C-Bahrainwala AH, Ebbinghaus S. Asthma management
  by an inpatient asthma care team. Journal of
  Pediatric Nursing. 2003 May-Jun29(3)177-83.
• D-Greineder, D., Loane, K. and Parks, P., 1999. A
  randomized controlled trial of a pediatric asthma
  outreach program. The Journal of Allergy and
  Clinical Immunology 103 3, pp. 436440.