1National
Asthma Education and Prevention Program (NAEPP), National Heart,
Lung, and Blood Institute (NHLBI). 2002. NAEPPExpert Panel Report: Guidelines for
the Diagnosis and Management of Asthma - Update on Selected Topics 2002. (http://www.nhlbi.nih.gov/guidelines/asthma/index.htm)
| |
Identifying a CMHA
Program Champion within Your Clinic
The primary responsibility of the CMHA program
champion is to become an authority on the program and to serve
as the primary coordinator in the planning and integration of
each phase of the program. This person will "champion"
the principles of the program and serve as an advocate for its
adoption. Leadership is an extremely important function of the
program champion because successful adoption of the program depends
on having someone who can effectively communicate the goals of
the program and who is empowered to take action. Implementation
of the CMHA program requires guidance and support from all levels
within the health care organization, and as such, it is important
that someone have a genuine interest in improving the approach
to asthma management and care in the clinic.
The choice of a CMHA program champion depends
primarily on the structure of the organization. It can be either
a formal or informal leader within your clinic who will support
and encourage the adoption of the program. Typically, this person
will belong to senior management and be considered a valuable
and respected leader within the clinic environment. Alternatively,
the coordinator may be an informal leader, such as a health professional
within the clinic who influences the staff and provides general
leadership of the clinic.
Answering the following questions may provide
some guidance in identifying a CMHA champion in your clinic:
Which
formal or informal leader is likely to support and encourage
the clinic to take a new direction?
Who
has influence over other formal and informal leaders in the clinic?
Who
will work with you to implement the program in your clinic?
Is
this person able to make decisions regarding the budget and general
strategic direction of the clinic?
Is
this person valued and respected within the clinic?
Will
the staff follow this person's advice?
These are examples of suggested questions. However,
based on your experience within your clinic, you may find it
necessary to ask additional questions to facilitate the selection
of an appropriate program champion.
A key to encouraging cooperation at all levels
is to become an expert on the program. The first step to becoming
an authority on the CMHA program is to carefully read the details
of the program and to understand what is involved. Supervisors
and managers need to be informed about how integration of the
CMHA program can benefit the clinic and how it will affect the
current mode of operations, particularly as it relates to asthma
management. Since it is the initial responsibility of the program
champion to become an authority on the CMHA program and he/she should have a
comprehensive understanding of the resources necessary to successfully
implement each component.
Additional responsibilities of the program champion
may include:
Creating
an awareness of the need for improved asthma management and care.
Promoting
the philosophy of the CMHA program and how it can benefit the
clinic and community.
Generating
support from management (e.g., funding, resources, approval)
and staff (e.g., cooperation).
Coordinating
the training and implementation of the program.
Working
with management to prepare a plan to ensure sustainability of
the program.
To aid the program champion in developing a comprehensive
understanding of the program, the authors have provided a series
of manuals that not only describes all the phases in detail,
but also offer a step-by-step approach to help you obtain the
information you need. These materials can be downloaded from
the CMHA website [To be inserted by NYCDOH]. The program and
training materials should be disseminated to appropriate staff,
as needed.
The next step is to obtain meaningful information
about how the program fits into the broader context of the clinic
and community. The next few sections provide detailed information
about the types of questions that should be addressed and types
of data that can be obtained to present a comprehensive picture
of the need for asthma education and intervention.
You can then use all the information to make
informed decisions about how best to focus your efforts and resources,
and evaluate the likelihood that the leaders in your clinic will
adopt the CMHA program.
| |
Conducting Assessments within Your Clinic and Community
In addition to identifying key decision makers
or advocates of the program within the health care setting, it
is important to understand your clinic's current approach to
asthma care and management. This will help you to brainstorm
about various approaches that may work to support implementation
of the CMHA program in your clinic.
Clinic Self-Assessment
A clinic self-assessment can be conducted to
summarize the clinic's current approach to pediatric asthma care
and management. By conducting a self-assessment of your clinic's
current operations, you will be able to understand the context of your clinic,
and assess how CMHA
can be beneficial and integrated into the daily workings of the
clinic.
Below is a list of sample questions, divided
into four key areas that can provide a foundation for conducting
the self-assessment of the clinic.
Current Asthma Management |
How are patients with asthma identified and diagnosed in your
clinic?
How many patients with asthma are treated in your clinic per
day?
What is the level of severity of asthma seen in your clinic?
What proportion of patients with asthma suffers from mild intermittent,
mild persistent, moderate persistent, or severe persistent asthma?
(See Appendix A for the Asthma Severity Classification
Chart)
Is the level of severity for each patient documented in patients'
medical charts at each visit, based on NHLBI guidelines?
What percentage of patients with persistent asthma receives long-term
controller therapy?
Do patients receive asthma self-management education in your
clinic?
Do patients have written self-management plans?
What percentage of patients make urgent visits for acute asthma
care to your clinic or local emergency care facilities?
What percentage of patients have been hospitalized for asthma
in the past year?
|
|
|
What do patients and their caregivers think about the way the
clinic works? Is the reception by staff friendly? Do they have
long waiting times? What works well and what needs to be improved?
Do patients and caregivers feel that they are receiving appropriate
care for their asthma?
Are the patients and caregivers satisfied with the amount of
time and attention they are receiving for the diagnosis and treatment
of asthma?
|
In addition to conducting an assessment of asthma
management in your clinic, you should also consider health professional
resources necessary for providing the current level of asthma
care within your clinic. You may want to think about the following:
|
|
Do the physicians or nurses feel overwhelmed with the amount
or difficulty of asthma care in the clinic?
What are some of the problems experienced by staff regarding
asthma care?
What are some of their suggestions for improvement?
Does management currently provide financial support for the professional
development of clinic staff?
|
Another important consideration when introducing
a program is the availability of resources compared to the costs
involved with implementation. In addition to the training costs,
there are costs for purchase of materials, labor time, and other
resources that may be needed. These cost categories are only
suggested and may be modified depending on the situation within
your clinic. The capacity and resources of each clinic may determine
the significant cost considerations. Below is a list questions
that can help you determine how resources are currently being
used and whether additional costs should be considered.
Cost Considerations and Clinic
Resources |
How can training be done with minimal impact on the normal work routine of clinic staff?
How many hours will be spent on training for each member of the
staff? Are there overtime labor hours available?
Can the clinic schedule the time needed to conduct training?
What resources does the clinic have available to support training
and implementation of the program? What other resources are needed?
What are the potential long-term economic benefits associated
with changing the current system?
|
Sources of Information -- Clinic or
Healthcare organization
Many sources of information within the healthcare
organization are available. They can help address the key areas described
above and assist you with creating an accurate picture of the
operations of your clinic regarding asthma management. Using
multiple sources of information will allow you to develop a comprehensive
estimation of the burden of asthma and how the CMHA program can
benefit the clinic. Potential sources of information include:
Medical records
Patient and staff surveys
Interviews with management personnel
Budget reports
Community Needs Assessment
Conducting a community assessment in addition
to the clinic assessment can provide a context for understanding
the impact of asthma on your community. This will also allow
you to evaluate how a program such as CMHA can benefit the community.
It may also be useful to compare rates in the community with
those in your clinic. The following questions are arranged by
category and can serve as a guide to understanding the local
asthma perspective.
Prevalence
Prevalence means the number of existing cases
of a particular condition, disease or occurrence (e.g., number
of persons with asthma) at a given time.
Have
asthma prevalence studies been conducted in your community? What
rates were found?
Mortality
Mortality is the number of cases that result
in death from a health condition.
What
are the annual mortality rates due to asthma in your community
in the past 10 years per 100,000 inhabitants? For children aged
0-14 years?
Have
any children died from asthma in your community or clinic?
Hospitalization
Hospitalization refers to admission to the hospital
for inpatient, outpatient, or emergency room services to obtain
treatment for particular health conditions.
How
many individuals were hospitalized due to asthma in your community
in the past 5 years? How many children aged 0-14 years?
Primary Care
Primary care means obtaining treatment from a
primary care physician during a scheduled office visit.
How
many outpatient visits associated with asthma occurred in primary
care departments in your community in the past 5 years? How many
visits for children?
Sources of Information - Community
To address questions regarding asthma within
the community, there are usually a variety of sources available.
By starting with the sources listed below, you can find some
reliable information directly related to the above categories
and questions.
Local
health departments
Local
hospital records
State
asthma program coordinator.
For information on state asthma programs and
state contacts, go to http://www.cdc.gov/asthma (click on state
asthma contacts and programs). Otherwise go to http://www.ced.gov/nceh/airpollution/asthma/contacts/default.htm.
It is very important to gather information from
sources that are consistent and credible. The information gathered
can be used to prepare a presentation for management and other
potential stakeholders to gain their support for the program.
The next section provides a more detailed discussion about coordinating
your data and preparing your presentation.
| |
Gain Management Support for the CMHA Program
Once you have identified a CMHA program champion
within the clinic to coordinate and advocate for the adoption
of the CMHA program, and have considered the internal dynamics
of your clinic and community needs, you now have the information
you need to gain management support for the program. Use this
information to demonstrate how the CMHA program adds value to
your clinic or health care organization.
To aid in the presentation of the CMHA program
to key decision makers, the authors have created a series of
PowerPoint slides that describes the basic details of the program
(i.e., the significance and goals of the CMHA program, results
of the program from the test clinics, the team-based approach, and
the training program). In addition, there are several blank slides
where you can insert the information you have obtained specific
to your organization and community.
This presentation kit, titled "Creating
a Medical Home for Asthma: Improving Asthma Care and Patient
Education," is included in Appendix B or
can be downloaded from the link provided on the top left-hand
cornor of the page.
When presenting the CMHA program to key decision
makers, analyze and describe the benefits the clinic will likely
see if the program is implemented. For example, the following
are a list of benefits observed when the New York City clinics
implemented the CMHA program:
Increased number of new patients with asthma identified by clinic
staff.
Increased treatment with anti-inflammatory medications for patients
with persistent asthma.
Improvement in patients' symptoms related to asthma seen by physicians.
Patients empowered toward self-management.
Improved patient education efforts in the clinic.
Trends toward reduced emergency room visits and hospitalization.
To ensure that decisions will be made following
the presentation, discuss next steps during the end of the presentation;
schedule a meeting to discuss the clinic self-assessment you
conducted to address specifically how CMHA can benefit the staff
and patients; and develop an action plan to assist with coordinating
the CMHA program in conjunction with the clinic leadership. A
sample clinic action plan is outlined in Appendix C.
| |
Coordinating the CMHA Program Training
Once clinic management has agreed to support
the implementation of the CMHA program, the next step is to coordinate
the training for the clinic staff directly involved with the
implementation of the program. Below are five steps that should
be followed to coordinate and prepare clinic staff for the training.
They are:
(1) Obtain CMHA training materials and resources;
(2) assemble the training team;
(3) organize the health care clinic team;
(4) develop the training schedule; and
(5) coordinate logistical arrangements.
Step 1: Obtain CMHA Training Materials
and Resources
In addition to this guide for getting started,
there are additional program materials that should be used for
training in the CMHA program. These manuals are provided as a
guide for both the trainers and the participants, to help each
group adequately prepare for and participate in the training.
The Instructor's Guide
is a resource manual that provides tools, lists of resources,
and background information needed to conduct the training. Much
of the information provided is specific to the program itself,
although it also includes key concepts that need to be understood
before training begins. The Instructor's Guide also contains
a section on interactive instructional strategies-such as role-playing
skits-that can be used to help all participants make the most
of the learning experience.
The Program Handbook
is a practical manual that should be used by the participants
during the training. It includes session agendas, handouts, instructions,
and key concepts that are used throughout the process. Participants
are encouraged to review the manual before the training and before
each session to prepare for the activities.
Additional resources that may be used to supplement
the training materials are available through the website. Resources
such as the Guide to Implementation and the supplemental materials
can provide some additional context for how the program will
be implemented in the clinic setting. Videos are also a necessary
tool for the training and are available in a video format.
Step 2: Assemble Training Team
The next step for the program champion when coordinating
the CMHA training is to assemble a training team. The training
team consists of a group of specialists who will be responsible
for conducting the training for the program. Creating a team
to conduct the training is central in the core team-building
philosophy of the CMHA program. Thus, emphasis is placed on communication,
cooperation, and collaboration throughout the entire process.
The training team should consist of at least three key individuals:
an asthma specialist, one or more group facilitator/health educators,
and a medical or administrative leader from within the organization
itself. This team may be supplemented by other health professionals
with a special interest or expertise in improving care for asthma.
These three individuals are vital to the success of the training
and each one plays a different role throughout the process.
The key individuals represent the minimum number
of individuals needed to conduct the training. However, the authors
recommend that additional individuals are included who have expertise
in other areas as well. For example, a person with expertise
in behavioral science can provide some additional insight for
the theories presented during the training.
Below is a description of the specific skills
or competencies needed to adequately staff each position.
Asthma Specialist
This individual should be a pulmonologist or
allergist who currently treats asthma patients. He or she will
be responsible for presenting and reviewing approaches to asthma
treatment, and teaching clinic clinicians practical ways to apply
the guidelines in their primary care setting.
Group Facilitator/Health Educator(s)
These individuals should have experience using
group processes to help organizations make changes to improve
the quality of their operations. Alternatives might be a health
promotions specialist or an organizational business trainer.
The facilitators should also be very familiar with the operations
and culture of the clinic staff. This can be accomplished by
providing them with a copy of the results of your clinic self-assessment.
Medical/Administrative Leader
This person should have a formal or informal leadership
role within the organization in which the program will be implemented.
He or she can be an administrator, medical director, or nursing
director. This individual's role is to guide the activities that
involve administrative changes, and to emphasize the commitment
to change and quality improvement.
Once the training team is assembled, the CMHA
program champion should provide each member with a copy of the
training materials, as well as a brief orientation on the philosophy
and goals of the CMHA program. Since they are likely to be unfamiliar
with the training process itself, they may find it helpful to
review some of the key areas of the program and the descriptions
of their roles and responsibilities.
The PowerPoint presentation described earlier
and located in Appendix B, may be a useful tool during the orientation
of the training team. Copies of the presentation should also
be provided to the team for use during the initial training session.
It will help provide context for the clinic as well as prepare
them for the areas that they should emphasize during the training.
Step 3: Organize the Health Clinic
Team
Implementing the CMHA program requires a committed
team working together and building relationships with patients
and families. Thus, the health clinic team is a critical part
of the overall program, and is the key to its success. This team
consists of clinic staff that will be trained in preparation
for implementation of the program. Initially, the health clinic
team is led by the program champion, with active participation
from the clinic managers. After the training, managers are responsible
for overseeing the implementation of the program and supervising
the performance of the health clinic team.
Clinic Managers/Supervisors
The clinic managers can provide the resources
and authority to implement the CMHA program. They need to be
informed and active members of the CMHA team because their activities
and decisions can have a direct impact on the quality and delivery
of the program. The supervisors are responsible for overseeing
the clinic staff as they initiate the program. A special one-day
orientation should be conducted that will prepare them for the
implementation of CMHA in their clinic and provide strategies
for maintaining the program.
Physicians
Physicians play a major role in this program
because they provide care and support for the patients with asthma.
Often, they can make decisions affecting the allocation of resources
and time for the staff in the clinic. Physicians have knowledge
and information regarding asthma and care for asthma that can
impact the implementation of the program. Throughout the training,
physicians will learn strategies that can enhance communication
with their patients, as well as receiving the latest information
on asthma management and treatment strategies.
Nurses
Nurses play a primary role in the care of patients
with asthma in the clinic. They monitor patients, and recognize
various trends in patients that may be early warning signs of
more chronic conditions. Often, nurses offer patient education
on various conditions, so their efforts will be integral to the
program.
Administrative Staff
Administrative staff members include all support
staff (such as receptionists, clerks, orderlies, laboratory technicians,
and medical records staff). They are a very important part of
the team because they generally are the first to greet families
as they enter the clinic and the last to address them as they
leave. Information about the program should be shared with the
administrative staff so that they understand their role in maintaining
good relationships with the families.
Other Clinic Personnel
Outreach counselors are a good resource for clinics
implementing the CMHA program; however, they are not mandatory.
They can provide aid and counseling to families in crisis as
well as follow up with families when they do not keep their scheduled
visits. Outreach counselors can play a pivotal role in extending
the continuity of care philosophy by serving as a liaison with
the clinic, the family, and the community. Developing relationships
with various community organizations allows the counselors to
provide families with information on community resources that
are available to support their needs.
Step 4: Develop Training Schedule
Although there is a set average length for each
training session, there is no set length of time allotted between
sessions. Therefore, this step requires extensive communication
between the training team and the health clinic team, in order
to coordinate scheduling for each session. Cooperation from management
is also helpful, and in most cases essential, in order to develop
the training schedule. The training organizers should be sure to communicate
with the managers and/or supervisors to determine allowances
for professional development, make alternative arrangements for
clinic coverage (if needed), and obtain approval for release
time or schedule flexibility for staff participating in the training.
Step 5: Coordinate Logistical Arrangements
Another important consideration in coordinating
training is the logistical arrangements that need to be made
in advance. In addition to the training costs, there are costs
for purchase of materials, labor time, and other resources that
may be needed. Below is a list of the potential cost considerations:
Materials and Facilities Costs
Reproduction of materials and handouts for participants
Reservation of training room, and audiovisual equipment, if necessar
Resource Costs
Labor hours spent on training for each clinic staff member
Any overtime labor hours due to training, if necessary
Catering (i.e., food and beverage), if needed
Monetary compensation for training team.
Finally, once the training has been coordinated
and logistical arrangements made, it is time to actually implement
the training efforts. Training materials consist of two documents,
the Instructor's Guide and Program Handbook, and
a video. Each of these resources is available through the website. If your
computer does not have the capability to download the video from
the website via streaming media, you can request a copy on a
CD from the New York City Department of Health and Mental Hygiene.
The contact information is available on the website and listed
on the title page of this manual. The first Instructor's Guide
is for the training team and provides information on instructional
strategies, activities, and related materials for each session.
The Program Handbook is for the training participants,
and describes key concepts, activities, and handouts that will
be used throughout the training.
Communication and advanced preparation are essential
factors in coordinating a successful training. All members of
the training team should be aware of their responsibilities throughout
the training, and have the information and materials appropriate
for the session and/or activities they will be leading. In addition,
clinic staff who will be participating in the training should
be notified several weeks in advance about the training schedule,
arrangements that need to be made before and during the training,
and any provisions that have been made for their absence. Allowing
staff plenty of time to plan for the upcoming training will minimize
the burden and encourage full participation.
| |
Technical Assistance
Program consultants are available to provide
support and technical assistance in addressing advanced questions
regarding program training and implementation. The program champion,
training coordinator, implementation planner, clinic staff, and
managers are likely to raise various questions and concerns.
Thoroughly reviewing the materials and developing a comprehensive
understanding of the program can help provide answers to most
questions. However, in some instances questions may arise that
require a technical response or detailed explanation that extends
beyond the normal scope of knowledge and expertise. These questions
can be directed to the appropriate consultant for technical assistance.
A team at Columbia University, led by David Evans,
Ph.D., developed the original version of the CMHA program. Dr.
Evans will serve as the primary program consultant and will provide
technical assistance for questions related to the program. The website lists contact information
for technical assistance consultants under the Contacts button.
| |
| |
Appendix B: Presentation Kit
The actual PowerPoint presentation slides can be downloaded
from the CMHA program website under Getting Started - PowerPoint
Presentation.
To view the slides on the Internet, Internet
Explorer browser version 4.0 or higher is recommended.
| |
Appendix C: Sample Clinic Action Plan
The table below is a sample "action plan
worksheet" for launching the CMHA program in your clinic.
What?
Steps/Activities/Tasks |
How? |
When? |
Who?
Activity/Task Coordinator &
Team Responsible |
|
Understand the CMHA Program:
Background and objectives
Local burden of asthma
The guiding principles
|
|
|
|
|
Identify a CMHA Program Champion:
An informal or formal leader to support the program
|
|
|
|
|
Understand the Internal Dynamics of Your Clinic:
Conduct a needs assessment of asthma in your clinic and community
Understand the team-based nature of the program
Understand the roles of various staff and their importance to
the program
|
|
|
|
|
Gain Management Support for the CMHA Program:
Present the CMHA program
Schedule follow-up meetings for implementation of the program
|
|
|
|
| |
