Asthma Project

Introduction

This project focuses on childhood asthma from 0 to 14 years. It is part of Kaipara Care Incorporated’s involvement in the Pilot Demonstration Integrated Care Projects - along with Diabetes and the Well Elderly. Asthma was selected as a disease management project as it is now one of the most common medical disorders in developing and developed countries, including New Zealand.

Within the Northern region, Northland and South Auckland have the highest age-standardised rates of Asthma mortality. There is greater incidence amongst Maori and those from the Pacific Islands. This may be due to socio economic status and living environment rather than any inherent predisposition to the disease.

Between 1969 and 1982 Asthma prevalence in New Zealand children almost doubled from 7.1% to 13.5% and between 1975 and 1989 increased among adolescents from 26.2% to 34%.(1)

Extrapolation from an Australian study which took into account doctors consultation, hospitalisation, ambulance, pharmaceutical costs and absenteeism from work suggests that the figure is likely to be around $195 million or more.

The management of asthma involves prevention and management strategies and includes the co ordination of primary and secondary health sectors. The primary sector focused on the prevention of asthma attacks and to assist the families and children to manage their asthma with the support of the health providers involved in their care. There is a particular focus in this project on the education of the child and family.

Recent feed back from both the children and families involved in the project show both Maori and Non Maori have indicated that gaining the information about asthma, and the education on how to manage the asthma, has given them the confidence and strength to manage their child’s health. Without this, the parents and child feel inadequate and fearful.

The secondary prevention strategies are based on early diagnosis, prompt and effective intervention with adequate referral and follow up. These strategies are an integral part of the Kaipara Care Incorporated’s Best Practice Guidelines, - which include, disease management, case management, care management and clinical pathways. (This is discussed in more detail at the end of this section.)

There has developed a close liaison between the independent service providers, the Iwi providers Te Ha o Te Oranga - the Mobile Maori Nursing Service., GPs and Dargaville Hospital. Bi-monthly multi disciplinary team meetings are held in order to manage the project and undertake the quality issues.

The database now has a register of 130 children and has been designed to contain the information required to assist in the quantitative outputs and health gains. The qualitative information is gathered in a variety of ways, from both the patients and the providers, through questionnaires, focus groups and case studies.

Much of the cost is born in the secondary care area but most opportunity to improve health status occurs in the primary care.In developing a coordinated care process for children with Asthma in the Kaipara area, the KCI project focuses on the prevention of asthma attacks - specifically those which result in admission to hospital and lost schools days,- along with the maintenance of health in those aged 0-14 years of age .

The project has now been in progress for 18 months. There have been changes and modifications to the original plan.This outline addresses, in brief, both the development and the changes.

1. Disease Management
   

   To establish the existing level of service provision on a needs analysis basis, a study was carried out. This involved the administration and analysis of results from a confidential questionnaire to both the community and health providers.

   An audit and analysis of the current Asthma care was completed at Dargaville Medical Centre and inpatient care at Dargaville Hospital, to determine the then current clinical practice being administered. All the existing physical Asthma resources were identified. An in depth resource and cost analysis was not completed.

   The Best Practice Guidelines were developed through a consultation mechanism which established the then existing asthma service providers clinical approach. This included the following:

   • Public Health Nurse
   • District Nurse
   • Dargaville Medical Centre
   • Dargaville Hospital
   • Asthma Society
   • Iwi providers
   • Pharmacy

   Consultation on Best Practice Guidelines with key Asthma and respiratory specialists, Starship Children’s Hospital, IPA and others providing similar Asthma care in other regions. Consultation with CHE respiratory specialists.  Consultation with others involved in Asthma care in Northland.

   The final decision on the use of Best Practice Guidelines was based on a consultative process and agreed upon, with a commitment to trial the Best Practice Guidelines given by all parties for 3/12 period.

   This, in fact, did not happen. A multidisciplinary team was set up almost immediately to ensure there was an established communication pathway between providers. A quality monitoring system was implemented which lead to an internal audit of the Guidelines nine months later.

   A manual was developed with input from the multi disciplinary team. This manual was signed off by the provider executive managers involved in KCI and was then issued to the providers.

   Flow charts were developed and a referral pathway included. The involvement of the Hospital and Public Health Nurses was extrapolated on.

   The manual undergoes annual reviews and is updated as required, as part of the quality process.

2. Care Co-ordination Systems
   The identification of gaps and barriers to effective service delivery and strategies were identified. Strategies were put in place to manage same. Formalised systems of referral and documentation are well established and consistent between Asthma service providers. The systems are included in the manual.. Referral forms between nurses and GPs have been developed to better pass on information about patients.
   The multi disciplinary team has been working to ensure the iwi service provider Te Ha oTe Oranga (Mobile Maori Nursing Service) is included in the referral pathway and to spread the load of work between the nurses involved. In particular, we discovered the over use of what has been named "the precious one" - a phenomena also found in our Diabetes project - was leading to an over load of referrals to one person.
   
   Memorandum of Understanding

   The memorandum of Understanding between Kaipara care Incorporated and Ngati Whatua is a written document which out lines the commitment of each party to work together toward a greater resolution and the development of a bi cultural model of coordination, with a Deed of partnership.

   The commitment to a bi-cultural model is from governance, management and practitioner levels. All of the implementation of this project, and others, has been with Te Ha Te o Oranga and iwi. A close and trusting relationship continues to be fostered. The development of this relationship has depended on the inclusion and acceptance of both parties in joint project development. The KCI project manager, Lynn Messervy, and Team leader of Te Ha o Te Oranga, Dianne Lawson, never assume anything except to consult, plan and evaluate together. Hardly a day goes by without some communication between them.

   During the time this project has been operational Te Ha oTe Oranga has gained greater acceptance by other providers as the work they do, and the recognition from iwi, grows. The challenge we face now is to encourage other providers to refer patients to Te Ha oTe Oranga for follow up and education. All of the nurses at Te Ha o Te Oranga have been well updated in matters relating to asthma.

3. Case Management
   

   A multi disciplinary Team was established to oversee the Asthma project. This team includes a consumer representative and the Asthma Society nurse educator. This arrangement has promoted collaboration between all service providers, including iwi.

   It was envisaged a register would be installed that linked all service providers with a priority register of high need Asthma clients to established multidisciplinary case management of these families.

   Again, this did not happen. A database of information was established for all those 0 -14 year olds with a diagnosis of asthma. The data collected is for the specific purpose of measuring outcomes. Privacy issues were attended to and permission gained from all asthma patients/guardians to collect this information and be held on the KCI Data base. In the long term, it is expected providers will have access to this information. However, the technology required is yet to be mastered, so will be done in combination with other projects and information requirements.

   As we worked with Te Ha o Te Oranga, we discovered that the strategy we used for Non Maori also worked for Maori. The ethnicity data being collected in the approved manner of self identification.

   Service Providers were not trained, as was planned, to use the register as it did not eventuate. Rather, they were trained to collect the necessary data, with updates of this data presented at the multidisciplinary teams.

   The case management aspects of high need families focused on the Asthma Nurse, who is employed at the Dargaville Medical Centre. The Asthma nurses role is to recruit the newly diagnosed patient onto the project, gain permission from the patient to be on the register, maintain the data base at the medical centre and to provide the education needs of the family. It is accepted the Asthma Nurse will give patients the choice of provider, and refer patients onto other appropriate service providers for the support and education - in particular Te Ha oTe Oranga.

   The data base is maintained by KCI. who now have a data collection person. . This has lessened the work on the providers. It is worth noting that collecting data from schools was difficult, compounded by issues about privacy not clearly understood by the schools or nurses involved. The data collection person and the project manager developed a data collection plan and the information needed from schools is now being received.

   An audit of Asthma care was undertaken last July. Included in it were satisfaction surveys and interviews with consumers and providers. Outcomes of this audit were addressed by the multidisciplinary team. Action was taken as necessary.

4. Professional Development
   

   All service providers involved in Asthma management have received ongoing, current up skilling in best practice Asthma. The Asthma Society and Northland Health Asthma education services. have been accessed for such training as necessary.

   The G.P. group professional development needs addressed by Respiratory Specialists in:

   i Evaluation and adaptation of Best Practice Guidelines ii Case management discussion forum 6/52.

   Nursing Practitioners training is addressed by CHE Asthma education services and in-service education at Whangarei Hospital.

5. Out Come and Performance Measures
   1. There will be a 60% reduction in the number of children (0-14 years) admitted to Dargaville Hospital/Ward 2 Whangarei Hospital, with acute Asthma
   2. 90% of children (0-16 years) with a diagnosis of Asthma from date of implementation of Best Practice Guidelines, will have a current Action Plan.
   3. 90% of school children (0-14 years) and children in pre-school care centres, with Asthma, will have an Action Plan on their school records.
   4. 90% of children (0-14 years) with Asthma will be followed up by the Asthma Nurse 4 weeks after an acute exacerbation of Asthma that requires GP or Hospital treatment.
   5. Customers and providers express satisfaction with the current delivery and direction of Asthma service in the annual consumer satisfaction survey

Shaw R.A., Crane J., O’Donnell T.V. et al.
Increasing Asthma prevalence in a rural N.Z. adolescent population: 1975-89 Arch. Dis. Childhood 1990.

Crane J., Howden-Chapman P.
The Prevention of Asthma with particular reference to Maori and children discussion paper for Midland Health 1997.