CDC Teleconf Asthma Triggers 101006

Slide1: 

The Association of Clinicians for the Underserved Effective Measures for Reduction of Indoor Asthma Triggers www.clinicians.org CDC Asthma Teleconference October 10, 2006            

The Association of Clinicians for the Underserved: 

The Association of Clinicians for the Underserved Mission to improve the health of underserved populations to enhance the development and support of healthcare clinicians serving these populations Cooperative Agreement with EPA National Advisory Board Partnerships with local, regional and national organizations

Goals of Training: 

Goals of Training Demonstrate effective approaches to environmental asthma education and management Asthma education and advocacy using the Chronic Care Model ©

Why look at patient education regarding indoor air triggers?: 

Why look at patient education regarding indoor air triggers? Asthma is one of the most common chronic illness among children in the US Common triggers are found indoors Insufficient provider education on prevention 90% of time spent inside in US New research shows behavioral changes are effective Team approach must be acknowledged

Asthma and Children living in poverty: 

Asthma and Children living in poverty Children living in poverty more likely to: use the ED care lack a primary care provider live in substandard housing

Personal and Social Impacts: 

Personal and Social Impacts Decreased self-esteem School absences Problems exercising can lead to obesity and other chronic diseases Physical, emotional, psychological Parental concerns Family stressors

NHLBI Guidelines: 

NHLBI Guidelines “Environmental Control Measures to avoid or eliminate factors that precipitate asthma symptoms…” Patient education that fosters a partnership among patient, family and clinicians Measures of assessment & monitoring Prescription therapy

Patient Education and Environmental Controls: Why doesn’t this happen?: 

Patient Education and Environmental Controls: Why doesn’t this happen? Provider issues Patient issues Complexities of disease Source: Cabana, MD, et. al, Barriers Pediatricians Face When Using Asthma Practice Guidelines (2000), Arch Pediatric Adolescent Med, Vol. 154.

Provider Barriers: Focus on treatment: 

Provider Barriers: Focus on treatment Prevention and health promotion not part of training Children seen for acute exacerbations, not prevention

Patient Barriers: 

Patient Barriers Competing stressors Limited control over living environment, child care, schools, etc. Limited access to social services Cultural and linguistic realities

Patient Barrier: Poor Housing Conditions: 

Patient Barrier: Poor Housing Conditions Triggers common in most homes Many at-risk families are disproportionately concentrated in poor quality housing

Indoor Asthma Triggers: 

Indoor Asthma Triggers Dust Mites Mold Cockroaches and Rodents Environmental Tobacco Smoke Pets Heating Systems Consumer Products

Dust Mites: 

Dust Mites Tiny insects that eat dead skin Skin collects on anything fluffy The warmer and more humid the atmosphere, the more dust mites

Practical Reduction: Dust Mites?: 

Practical Reduction: Dust Mites? Allergen-proof covers Cost? Where? Donations from local stores, churches, community groups Wash bedding frequently in hot water Where? Washable window shades, reduce carpeting Is this feasible?

Practical Reduction: Dust Mites: 

Practical Reduction: Dust Mites Limit number of fluffy things Washable/dryable toys Frequent vacuuming

Pests: 

Pests Cockroach dust comes from roach body parts and dropping Rodents—hair, skin flakes, urine and saliva Reinforce to families they are not “dirty”

Practical Reduction: Pest Control: 

Practical Reduction: Pest Control Clean surfaces where pests have been seen Clean crumbs and spilled liquids right away Store food in sealed containers Put garbage in trash daily, seal trash bags, use cans with fitted lids Roach traps

Mold: 

Mold Mold grows on moist surfaces Molds are naturally present in wood, cellulose, and paper products   Source: EPA

Practical Reduction: Mold: 

Practical Reduction: Mold Circulate the air Use exhaust fans Dry clothes in properly vented dryer or hang outside Repair leaks A/C can help control humidity Decrease humidity/avoid humidifiers Clean mold when you see it first Find out what is possible and support that intervention

Practical Reduction: Mold: 

Practical Reduction: Mold Empty refrigerator and A/C drip pans Wipe down shower and tub toys Avoid standing water in planted pots Clean up spills Physically remove mold via scrubbing off with brush Dry wet areas

Pet Dander: 

Pet Dander No such thing as non-allergenic furry pet Skin flakes, urine and saliva After removal, it may take months to reduce allergen level Does the child spend time at someone else’s house with pets? Dander can be brought into the home easily Does the pet sleep on a rug?

Practical Reduction: Pet Dander: 

Practical Reduction: Pet Dander No pets in sleeping area Vacuum and clean pet areas as frequently as possible Consider finding another good home for the pet or keeping pet outdoors

Tobacco Smoke: 

Tobacco Smoke Strong irritant and asthma trigger Other serious concerns from breathing secondhand smoke Gender roles and cultural customs may be a factor Source: EPA

Avoidance of Environmental Tobacco Smoke (ETS): 

Avoidance of Environmental Tobacco Smoke (ETS) No smoking in presence of child at home, childcare, or in cars There may be lack of affordable, smoke-free child care Resources for smoking cessation—cost, time, place, language?

ETS: Reduction: 

ETS: Reduction Low income smokers more likely to reduce tobacco use in response to increased prices for tobacco Lowering the cost of smoking cessation meds, patches and classes increases success Support non-smoking spaces for children Providers knowledge level of appropriate classes and Rx management Support Smoke Free-Legislation

Combustion Appliances: 

Combustion Appliances Nitrogen dioxide is an odorless gas that can irritate your eyes, nose, and throat and may cause shortness of breath. This gas can come from the use of appliances that burn fuels, such as gas, wood, and kerosene Source: Heritage Energy

Practical Solutions: Heating: 

Practical Solutions: Heating Ask patients how home is heated Become familiar with landlord-tenant issues in your community Be willing to write to a landlord on behalf of the family

Consumer Products: 

Consumer Products Cleaners, paints, adhesives, pesticides, air fresheners and cosmetics Be aware of symptoms of asthma when using these products Perfumes or anything with a strong scent/odor What are the family’s cultural practices related to this?

Practical Reduction: Consumer Products: 

Practical Reduction: Consumer Products Limit exposure Use in well ventilated areas Follow directions on label Educate patients on these forgotten triggers

Indoor Air TriggersA Health Promotion Focus: 

Indoor Air Triggers A Health Promotion Focus Health promotion skills are different than those needed for diagnosis and treatment The Chronic Care Model is a framework to organize the system One provider alone can’t do it all Source: Big Doctoring in America

Slide31: 

Image used with permission of Improving Chronic Illness Care

CCM: The Community: 

CCM: The Community Other agencies can help Use home visitors Understand housing law Become a patient advocate for safe and affordable housing Strengthen community groups

CCM: Home Visitors as Resource: 

CCM: Home Visitors as Resource Promote expansion of existing home visiting to include assessment of indoor asthma triggers Identify potential triggers Educate patients on trigger reduction Use EPA Home Check List http://www.epa.gov/asthma/pdfs/home_environment_checklist.pdf

Slide34: 

Consider a picture to help families indicate where more asthma attacks occur Source: http://www.usyoga.org/html/yogasthma/images/graphics/triggers.jpg

CCM: Housing Policies: 

CCM: Housing Policies Vary by state Local housing office Landlord-tenant advocacy organizations There may be other units or dwellings with the same problem---there is strength in numbers

CCM: Primary Care Providers in the Policy Arena: 

CCM: Primary Care Providers in the Policy Arena Testimony Educational programs for housing managers Training for medical team regarding patient legal rights

Advocating with patients: 

Advocating with patients Families may find it hard to “complain” Provider can write letters to landlord Providers can work with local housing groups on safe, affordable housing Dear Mr. Landlord, The mold and mildew in the Gonzalez apartment is bad for Carolina’s asthma. Please fix the leaky sink which causes mold to grow. Thank You. Sincerely, Dr. Bea Healthy

CCM: The Health System: 

CCM: The Health System Create a culture, organization and mechanisms that promote high quality care Senior officials must identify care improvement as a goal

CCM: Self Management: 

CCM: Self Management Promotes relationship in which families and professionals work together Recognizes and respects the knowledge, cultures, skills and experiences of professionals AND families Source: Family/Professional Collaboration for CSHN and Their Families, Family Professional Collaboration Project, 1993.

CCM: Self ManagementCultural Collaboration : 

CCM: Self Management Cultural Collaboration What do you call your problem? What do you think has caused it? Why do you think it started when it did? What does the sickness do to you/your child? How does it work? How severe is it? How long do you think you will have it?

CCM: Self Management Support : 

CCM: Self Management Support Empower and prepare patients to manage their health and health care Patient Control Goal Setting Problem Solving Internal and Community Resources

CCM: Delivery System DesignorHow is Care Provided?: 

CCM: Delivery System Design or How is Care Provided? Assure effective clinical care and support Regular f/u visits Consider group educational visits Outreach workers Check list Is clinic meeting cultural and linguistic needs of patients?

CCM: Decision Support: 

CCM: Decision Support Promote clinical care consistent with scientific evidence and patient preferences Provide training to staff on indoor air trigger reduction Tool card reminders

CCM: Clinical Information Systems: 

CCM: Clinical Information Systems Asthma registry to track exposures Billing codes Check lists in chart Reminder systems Cues in EMR Charting on cultural beliefs and language preferences

Environmental Management of Asthma: 

Environmental Management of Asthma Many families can take steps to control their child’s environment Chronic care model is a framework which supports partnerships and institutional support Health care community can address social, environmental and legal factors that impact children’s health

Slide46: 

Patient education, partnerships, and advocacy are the keys to success! For more information www.clinicians.org lwessel@clinicians.org

National Expert Advisory Committee: 

National Expert Advisory Committee Amy Friedman, MPH- Allies Against Asthma Asha Subramanian, MD- Georgetown Fellow Bonita Wilson, MD- AAFA Ed Zuroweste, MD Migrant Clinicians Network Ellie Daniels, MD- National Center on Primary Care Jacqueline Spain, MD, HRSA Asthma Collaborative Janet Phoenix, MD, MPH- Coalition for Environmentally Safe Communities Katrin Kral - EPA Leigh Hume, RN- Inova Fairfax Hospital- Health Source Mary Jo Harris , RN- Baltimore City Health Department Peter Gergen, MD- NIH Shawn Bowen, MD- Children’s Health Fund Sheila Brown- EPA Suzanne Bronheim, PhD- National Center for Cultural Competence Tracy Goodman, JD- Children’s Law Center Jen Sheen-ACU Lois Wessel, CFNP-ACU Kathie Westpheling, MPH-ACU

Resources: 

Resources EPA Indoor Air Quality Information Clearinghouse www.epa.gov/iaq/asthma Allergy and Asthma Network/Mothers of Asthmatics www.aanma.org American Academy of Allergy, Asthma and Immunology www.aaaai.org American Lung Association www.lungusa.org Asthma and Allergy Foundation of America www.aafa.org American Association for Respiratory Care www.aarc.org Association of Clinicians for the Underserved www.clinicians.org