The session provides the opportunity to learn what constitutes quality pediatric asthma care, the components of a community asthma program, and how these both tie into overall mission and outcomes of the Healthy Kids Express Asthma Program.
Um, our symposium committee member, Doctor Beverly Brozanski, Susan and James G. Gold, professor of pediatrics, vice chair of Quality and Safety, Washington University School of Medicine, vice president of Pediatric Quality and Patient Safety for BJC Healthcare East and Saint Louis Children's Hospital. Please join me in welcoming Beverly. Thank you, Beverly. Great talk. I really enjoyed it and we're gonna switch to pediatrics now. Now this is a near and dear topic to my heart as the social determinants of health and the pediatric patients with diabetes and asthma are like a focus of work that we're doing at Children's. So I'm happy to introduce Anne Bergmeyer. Who's a pediatric nurse practitioner in St. Louis Children's Hospital Healthy Kids Express Asthma Program. It's a great program that's sponsored by children. She received her doctorate of nursing Practice from the University of Missouri in St. Louis, and she has more than 30 years' experience working with children, um, with asthma and Not only in the inpatient, but also in the outpatient setting and going to our schools. She's published, um, on the role of the nurse practitioner on asthma and obesity and, and the asthma action plan. So, thank you, Anne. Thank you. Um, I spent most of my career here at Children's in the inpatient, um, area working to save kids' lives who were admitted with asthma, so I never worked with them in the emergency room, nor did I really. I saw some in the PICU but really wasn't caring for them in the PICU. But then when I retired in 2018. Um, and I, I'm one of the few people you'll ever run into that really failed retirement, so very shortly after that I started working for, um, the asthma program in the community, and I really feel like it was such a blessing to me because, um, I started to see the potential for preventing some of what I was seeing in the hospital. So I feel very fortunate um to be part of the Healthy Kids Express asthma Program where I'm a nurse practitioner in that program. So what we do is we try to provide quality specialized asthma care in the school-based setting to children in underserved um area schools, and I'm gonna approach this from kind of showing you what we do in our program. I don't have any unfortunately financial relationships to disclose. Um, today I'm hoping that um you'll come away with understanding a little bit about the current state of asthma in the community. You'll be able to describe our program and you'll describe how it improves the quality of care for the kids that we see. So I just want to show you where we sit in the hospital. So Tesh Jewell is the vice president for ambulatory and clinical support services, and so we're under Tesh, Nicole Cosmar, director, and then you'll see all the different programs that are in our community outreach programs for child health advocacy and outreach. So we have Healthy Kids Healthy Minds. We have school nurses actually embedded in the St. Louis schools. You'll see my box in the middle and I'm gonna show you a little bit more. We have Raising Saint Louis Teen Outreach Safety street camp programs, and we also do a lot of program evaluation of all of these programs, but this is where I am housed, um, so it's asthma and then virtual care asthma, and actually I'll be telling you that I right now I'm doing most of the virtual care asthma, but we have both programs, and I'll tell you about them. So our goal is, oh, and first of all, I should tell you that in 2003 there was a, a community needs assessment done and um we capitalized on an opportunity from the foundation to do some community outreach and in that needs assessment, the number one thing in all the areas, especially in the schools, was they needed help with asthma. And so as you know, Saint Louis is a hotbed for asthma. We have more asthma than the national average, so the national average is probably a little more than 6%. And here in Saint Louis, all comers, um, we're probably close to 9%, and then we know there's disparity, right? We know that black children and children in poverty have an even higher rate than that. So it wasn't a big surprise to anybody that where they were looking for help was asthma. So Lisa Meadows at the time, with the help of um Bob Strunk, Doctor Strunk, um, developed the program where and there were other mobile van programs at the time, not very many, but based on the success of those programs they started our asthma van program. And the goal remained the same so we um want to meet the children where they are at school assess and plan, make sure their plan is following along the national health um guidelines that they've got. The medication they need that they have an action plan at home and at school that um we were gonna communicate with their providers and their caregivers and that we were gonna follow up uh in the program but also see that they're following up in the community we also just by nature of seeing the kids at school where they are we were decreasing some barriers to care. So for lots of our um children transportation is an issue, but if they get to school they get to see us and so we were taking that barrier out um cost thanks to the foundation is not an issue um and so we do not have to turn anyone away who signs up for our program they're able to be in the program um we aren't charging for our services at all. Um, we, um, make sure they have access to medication equipment. Um, we are really providing almost specialist care because we are in collaboration with the pulmonary allergy, um, physicians from WashU, so we feel like we're providing specialty care to these kids in that convenient health care setting at the school. Um, we try to coordinate care and, um, we work on health literacy for the child as well as the parent. That's our asthma action plan that we also we utilize all the same tools that we utilize throughout Children's Hospital so we utilize the same action plan that you see in the inpatient setting or in any community setting where you're using our plan. Um, so how do they get into our program? So really schools apply to be in our program, so. Um, um, we send out messages that let them know we're here and that we're available. They apply and we have a rubric for selection. We try to keep each school for 3 years, so we have turnover, but we do keep the schools for 3 years. So, uh, we go by the number of students with asthma, so we want it to be worth our while to drive the van to the school. So we wanna make sure that they have a significant and plus that shows they have more need because of the numbers um we look at the ED utilization by zip code for the school we um look at the percent of students with asthma so in a really large school what is their percent. Then we look at the household income based on federal poverty guidelines for their students. We look at the distance to a healthcare facility. So, um, we're trying not to go and park our van right next door to a federally qualified clinic. We want to make sure that we're hitting the kids that couldn't get to the clinic very easily. Um, we look at school nurse to student ratio, as you know, some schools don't have school nurses, and so those schools would get bumped up in the priority list if they do not have a school nurse. Um, availability of a health aide at the school, so that goes in with the school nurse. We wanna see who's there to take care of the health of the kids, um, and also if they have a high special needs population, we would bump them up too. So if it's literacy, uh, language, uh, any special health care needs, we are going to consider all those things. So there's a rubric that they get scored on the schools and then we select schools of course we don't have the ability to take care of every school that applies. So, um, I'll be showing you what we have been doing in this last year. Um, this is it. Uh, so these are the schools we're in the last year. You can see we're in just 2 Saint Louis public schools right now. When we started out we were in a ton of public schools and so we've kind of moved on to some other areas and I just heard the conversation on, um, next year's schools and we're gonna be back to more Saint Louis public schools next year. Um, we're in the Ritner School District, the charter school in Normandy, Riverview, Hazelwood, and Jennings. You'll see we're kind of concentrated in Hazelwood right now, and when I show you a map in a minute, you'll see probably why that is. Um, So this is a map and you know forgive me it's not really a pediatric map but it goes along the same lines as pediatrics but it shows dense populations with asthma zip codes that have a lot of asthma prevalence and then I put in where our schools are located and those two that are kind of hanging out in the white, those are our two public schools in the city. Um, but I found this county map that showed, and it, it was, it was kind of good for us to see when I put them on here that we are in that darkest area. We are very concentrated in the darkest area. As well as some surrounding areas and so um those are the schools we're in right now. um, next year I expect us to continue to be in a lot of those schools as we pick new schools. Remember they get bumped up for being in areas of high asthma or federally, uh, the federal poverty guidelines. So I think we will move to a different school, but most likely we will still be in those areas that are dense with prevalent asthma. Um, this is our whole program, um, all of the numbers of kids that we touch in the advocacy and outreach, and it's really, um, 15,843, um, kids are touched by us, um. That's 143 schools in 17 districts because it's not only asthma, we have dental, we have diabetes, and so you will see that in the asthma Healthy kids express asthma, 769 students participated. And then down here we don't have a number for the asthma virtual, we just have that big number 367 individuals for behavioral health and asthma, which are two virtual programs, but we had about 50 students in our virtual asthma program. Consent is, um, I mean, it's the first thing we have to do, right, and there's a lot of barriers to it right now. It needs to be signed. It's on paper. It's not electronic. We have to complete them yearly, according to our legal team. Um, and so we do a lot of recruiting. We have to spend time recruiting, so people say, what do you do in the summer when there's no school? Well, first of all, we do a lot of outreach activities, um, but we also do a lot of recruiting and so we go wherever those students are for the schools. So we'll go to school fairs, um, school sign ups, and we recruit students. We also, I don't know what we could do without the school nurses because when they see a kid in their office with asthma they're sending our, uh, consent home. So you know it's a good time they capture the kids for us so we have a lot of school nurse help and then we use all of the school information, uh, and communication platforms to try to attract kids. Um, our team is, uh, diverse, so we have nurse practitioners, nurses, we have to have drivers. Some of our nurses are drivers. Um, I heard one of our nurses say that that was a really big bonus to, to signing on with us that. She, she now can drive this huge van that I don't even wanna think about. Um, we have asthma coaches, community health workers, and I'll show you a little bit about their work. Um, we have a lot of administration and support staff. They schedule our patients for us. We have, um, respiratory therapists in the children's lab that train us in spirometry because it's one thing that the van is able to offer. We work with our uh colleagues, the Washington University allergy pulmonary medicine physicians, and then of course the school nurses and administration and every school that we go to, we do extensive education of not only the nurses and the administration but the staff that's there so all of the staff get education. Um, this is an in-person visit that's the middle of our van where we do spirometry. Uh, in back of, uh, Kendra you would see, uh, two like different sofa areas and in the middle of the table where we can begin our visits with the kids and then that kind of not very good picture is out through the front of our van and actually that area becomes one office and then there's an office in the back as well. So, um, we do have scheduled visits in Epic. We, um, the team rides in the van and parks outside the school and, you know, unfortunately that is a limitation to signing up some schools because if we can't go there and park. Um, it limits our ability to go there. So it's one of the first things our, uh, administrative team has to check all of that out. Will there be a place for us to park? Can we get out? Can it, you know, if the parents are lined up to get their kids, can we still get out? That those kind of things you just don't think about, um, and then the students are escorted to the van from the school nurse office, and they bring all their medicines and equipment they have at school. Um, we begin the visit in back of Kendra where the staff and all of our, uh, staff is co-trained, so our drivers even know how to administer the, um, child asthma control test and how to assess inhaler spacer technique. They go through tons of education for that, um, and then we educate or re-educate regarding asthma, the inhaler spacer technique and the asthma action plan. And then the nurse Kendra would in this van would perform the pre and post spirometry, and that's a huge bonus. You don't go to many even um pediatrician offices or federally qualified clinic where they're able to do the um spirometry, and I'll show you kind of why that's important in a second. Um, so then it's a focused visit with the PNP much like you would go to any visit at, um, any office. Um, they're making follow-up calls for additional history. There is an adult or parent component of the child asthma control test. Um, they develop a plan. They consult with the PCP if there's changes or concerns, um, by phone. They, uh, make sure every kid gets a spacer. Um, they make sure prescriptions go to a preferred pharmacy pharmacy. They document in Epic. Anybody can see our notes in Epic. It's under Chow, and then, um, we send notes on the action plan to the PCP, the school nurse, the parent. Um, just to show you, we do use the validated childhood asthma control test. There's two different ones. This is the one most likely we're using 4 to 11. Most of our kids fall in that age range. We do have a couple of high schools right now though that would use the older one. We do use a standardized um um way of grading their spacer technique which I never realized how important it is because we document it's simple to document in Epic and you can see each time you can see the progress they make, you can see what they had trouble with the last time and it you just pull it right up and it's there and so it helps us track how effective we are. Oh, and you could see there's one with a spacer and without. We use the book for education that we use all over the hospital and in any, uh, community settings too. So spirometry we use for those of you that know about it, Bree's Sue software. We try it with kids 5 and older. We try to test every 1 to 2 years. We prioritize the students with a lack of control or moderate persistent asthma, and that's for the national guidelines. That's who they say to prioritize. And then we retest if we're not able to get reliable results. We use a Z score and we update the results. So we're looking at. How much small airway disease they have, um, how much they can blow out, how obstructed their airways are, those are the things we're looking for in objective measurements with our spirometry. Um, the virtual visit, we don't need to go through all this, it's really in essence the same, um, and it's really been a privilege to participate in this. So this is my screen from home where I see my navigator putting the otoscope into the child's ear and both the child and I can see his, his eardrum. I am so spoiled by this when I actually. have the otoscope in my hand. I'm like, oh, where's that big picture that I'm always looking at and the kids love it. Um, after they have a couple visits, they come in and say, can we just look at my ear first, you know, like that's the most, but we do a focused exam, so we do. I have a stethoscope that I'm able to listen to their lungs and their heart with, um, and then we look at their ears, their nose, and their mouth. And uh, a kid that I just saw this week after I looked in his mouth, he said, wait a minute, can you go back and show me that again? Was there something weird in all right, I'll show you, but there wasn't anything weird, um, so I do have the virt the navigator at the school. He's not really virtual. He's a navigator. Um, and then I'm at home. We use Teladoc and um, so that navigator and I kind of do the whole visit together. So if as he's doing the childhood asthma control test, I'm there listening, um, as he's uh assessing the technique for the spacer and healer, I'm, I'm listening and we both kind of add into education. Um, one advantage is we've been at the school more than 3 years. We've been at our virtual school, so it, it kind of came about during COVID, and we have remained at those schools and it's, um, we have high, um, asthma at those schools and so we've gone down younger each year and so we're seeing kids 4 and older. But the rest of it's the same except no spirometry. Now one summer we did 2 summers ago, we parked the van outside the school and invited parents to bring their kids if they wanted spirometry, and we're planning to do that this year. Um, that's just a schematic, and there's our, the virtual equipment doesn't look very weird, right? Um, so the benefits. So in the early years 2008 to 201011, we were really convinced we were on the right track because we had 1,071 participants in the program in those in that time period. And we reduced, uh, we had a reduction in ED visits. It's from the year before to the end of the third year. Um, we went from 36.9% to 14.2%. We had reduction in hospital hospitalization from 7 to 5%. Absenteeism improved dramatically. From 59.1% to 27.1% and when we talked to parents, they said that's because they felt like when their kid was having a little bit of trouble in the morning they could send the kid to school and they were confident that if the kid needed extra help they would be contacted. So it was that developing that rapport with the parent, I believe that and plus we had them all on better programs, you know, we figured out what they really needed and got them on a better program. Um, we had improvement in our technique, and 96.9% of parents scored the program as excellent or very good. Yeah, it was good. My fear was always that I would call the parent and they wouldn't have time to talk to me, but you know, they're, they're really good about if they don't have time at that moment calling us back. So, uh, the demographics, um, we had more, um, boys than we did girls. If you look at race, we are hitting right where we need to hit there with 90, 0 wait, am I wrong? Is it 90, 90% of our, um, students, um, being black. Or African American, um, they self state for us, but we do have a variety of minorities in our little wedge. Um, we really have very few, um, white kids in our program, and it's by nature of the schools that we're in. 2% of our kids are white, um, and then this is last year's data, um, the grades, it's really kind of split in force if you look at it, but we have 6th through 8th grade. Um, that is one part of that pie, 4th and 5th, 2nd and 3rd, and then pre-K, um, to 1st grade is the other pie, so you can kind of see the ages of the kids. We have made 2064 last year contacts with those families and we completed 3,647 visits with the students. Um, I think that's what's important. Yeah, we had 902 students enrolled in the program last year, including the virtual care students. Um, average tech tech scores is kind of interesting. You can see that our virtual, uh, I think it's skewed because our virtual kids started at a higher level on the right, and it's because they've probably been in our program longer than those kids that are in, um, um, the in-person schools, but you can see that everybody improved in their tech check score. This is important here when we talk about disparity. Um, we have our community health workers. A lot of the nurse practitioners and nurses are able to go to bat and get medicines and things like that. We do our share of all those things, but when we have someone who's unhoused or when we're unable to get insurance coverage, we actually have someone we can call to get insurance coverage. We have issues of home remediation where our community health workers have resources for that. Um, we help with rent, um, electricity bills, um, getting primary care providers. I mean, I had a kid who was kicked out of two primary care providers for not showing up, you know, and we were able to go to bat for that family and help, and our community health worker got him transportation, so, you know, we utilize our community health workers. We had 85 students that were, that received 138 visits from the community health workers. Um, we wear a lot of hats. Um, we just, we, we published, we looked at the childhood asthma control test and spirometry. So how did it compare if somebody looked like they were, um, um, uncontrolled on the childhood asthma control test, were they uncontrolled when we looked at their objective lung function? And what we found was that 35% of children with the childhood asthma control test indicating well controlled. Really had spirometry that showed lack of control, so you know it's discouraging, but it's important to know because it means that using the childhood asthma control test is useful but we can't forego the provider assessment, the spirometry, and just really. Looking at medication and you know, kids, poverty level kids, studies have been shown that they um that they don't take their medicine as much as other people and when you look at the barriers they're facing getting the medicines, adhering to the medicines, having a parent home to give the medicines, you can understand all that. Um, so we did publish that. So we did, it did show that if you had an FAV1 of 80% or less, they did have a lower, um, childhood asthma control test, but the cut point was not as clear as we would have liked it to be. Um, and then right now we're in a an air quality and asthma, a study that's funded by the Quad AI, the American Academy of Allergy, Asthma and Immunology, and we're in the first year of it, and we're at two schools right now, and what we're doing is assessing policy. Assessing student, parent and staff knowledge of um uh outdoor air quality and allergy and then we've got a sequential plan to educate. We're gonna use the ALA flags so parents when they drop their kids off will see a flag indicating air quality and um we're gonna have a plan in place um for, for parents for what they do based on different air quality days. Uh, So Lisa Henry is probably our most senior nurse practitioner and so I wanted to make sure that if you wanted to get in contact you could contact all of us. Nicole Crisp is also full time. I'm mostly virtual. I do go out on the van though. I fill in for vacations and stuff like that. It's always fun. And then um we have community health manager and a clinical manager, so any of those people are more than happy to talk to you about our program. So do I have
