The Value of RCPs as Asthma/COPD Case Managers

With preparation and planning coupled with outcome measures, RCPs can become valuable asthma and COPD case managers.

RCPs can bring value to patient care outside of hospital walls. Opportunities exist for those therapists willing to add to their current repertoire by developing new skills. RCPs have highly developed skills and competencies in the care of asthma and chronic obstructive pulmonary disease (COPD) patients. Skills and competencies that other health care professionals would need to develop to care for this patient population. My opportunity to develop a case management program began in January 1997, culminating with a pilot program that began in January 2000. My goal is to share my experiences and, by measuring outcomes, prove the value of RCP case management programs.

Asthma care has changed significantly in the last 10 years. Management has moved from treating reactive airway disease to treating asthma as an inflammatory disease. The National Asthma Education and Prevention Program (NAEPP) recommendations include four major components: use of objective measures of lung function; environmental control measures; comprehensive pharmacologic therapy; and patient education.¹ Developing specific skills with each component will add value to your case management program.

Case manager skills are focused on working in the outpatient arena. Hospitalized patients are under the direct control of health care professionals and become very compliant with the regime, including medication management, smoking cessation, and a break from the stressors and triggers of everyday life. Patients’ behavior changes once they are discharged to the home. Compliance with treatment plans at home is surprisingly poor and patient adherence to these plans becomes a major issue.

The basic service components of case management include patient identification, assessment, planning and resource identification, service implementation, program monitoring, and evaluation.² Other components involve the case manager’s personal education and skills, and tools such as clinical practice guidelines, protocols, and risk assessment.²

According to case managers Hjalmer Lofstrom, RRT, and Ed Birnbaum, RRT, essential communication tools for the case manager are effective listening, open-ended questions, negotiation, and psychosocial assessment skills. Our RCP case managers went through extensive training in behavioral modification skills by learning the motivational interviewing techniques.³ The ability to work with patients and not dictate to them is essential to effective case management. Case managers assess the patient’s willingness to make behavior changes. A common question is “On a scale of 1 to 10, how willing are you to quit smoking?” If patients are somewhere between 1 and 3, they are not ready and the case manager will most likely be ineffective in changing their behavior. If patients are in the 4 to 6 range, they are precontemplators and it is worth exploring their thoughts on the topic.³ Other open-ended questions to ask include “What do you like about smoking?” “What don’t you like about smoking?” and “What do you think about the health effects of smoking?” Taking communication classes on listening skills and behavioral modification has enabled case managers to be effective caregivers outside the hospital.

It is important to understand comorbid conditions, as many COPD patients have other diseases such as congestive heart failure (CHF). The role of a valuable case manager can be greatly enhanced by learning basic management skills of patients with comorbid conditions, and appropriate community/medical resources. This is an advantage that nurse case managers will have based on their education.

Additionally, a case manager needs to develop pharmacological management skills such as recognizing and addressing potential drug interactions for patients. A common example is understanding that taking beta blockers makes beta agonists ineffective. This is also important when considering before and after bronchodilators for pulmonary function testing (PFT). These skills are highly developed in pharmacist asthma/COPD case managers.

The national standards for managing COPD and asthma require PFT. Staff therapist have the skills for performing these tests; however, therapists will most likely need to improve those skills in order to meet the American Thoracic Society’s standards. Peak flow meters are inadequate for accurate testing, as they are very effort-dependent and the equipment varies in quality, reproducible results. The NAEPP asthma standards recommend peak flow monitoring for asthma patients.¹ However, in my experience, the reality of patients’ home life has shown that they do not regularly monitor and document their peak flows. We use both symptom-based monitoring for patients and peak flow monitoring for those who either are motivated to use them or have difficulty recognizing their symptoms of decreasing lung function.

Case managers must use comprehensive knowledge and skills to balance the physical, emotional, and psychological needs of their patients. They also need to develop social support to increase the credibility of the RCP case manager.2 To add more value to case management, developing social worker skills is a bonus. When managing patients at home, you will be working with the family’s social and work life that impact their ability to self-manage their asthma or COPD. It is not unusual for a patient to have an exacerbation when they “ran out” of their medications because they could not afford them. As a hospital-based RCP, you see them in your emergency department (ED). Family/personal stress can also precipitate exacerbations, so assisting patients in managing this stress is also part of case management. Dealing with a school’s drug-free policies—including inhalers—is also a challenge in case management. You will also need to recognize when you should refer patients to skilled social workers. Depending on your community’s demographics, case managers who are fluent in a second language are desirable.

Depression
Another comorbidity, not uncommon in COPD, is depression. Learning the signs and symptoms of depression and knowing referral resources will enhance the value of being a case manager. Basic assessment is needed for depressed mood, lack of interest in pleasure or life, guilt, sleep disturbances, appetite changes, energy loss, or fatigue, which are all potential signs or symptoms of depression. When any medical condition is outside the scope of practice of the case manager, referral resources should be identified and used for further evaluation of your patient.

Additional community resources required are diabetes specialists/case managers, weight management, smoking cessation programs, charity programs, and sleep specialists. A case manager has to evaluate the patient’s needs for such referrals and develop a referral source list. Referrals will depend on the patient’s health care coverage, as many health care plans limit referrals to identified clinicians.

Within our health care plan, case managers need to develop computer skills and learn an electronic medical record system. This record produces a significant advantage for our case managers by allowing them to review an outpatient chart in a matter of minutes. They can locate arterial blood gas and PFT results over the last several years, review each physician’s chart—including allergists and pulmonologists—at every office and ED visit. This is an extraordinary advantage over paper charts. Without the electronic medical record, case managers will spend a considerable amount of time accessing the outpatient records from many different sources in order to fully understand the patient’s conditions, comorbidities, medicines, disease progress, and family/social history.

Patient Selection
Patient selection for case management will depend on your program’s focus. It is essential that you stratify your patients in order to select those who will most benefit from case management. For example, you can stratify your patients based on ED utilization. Review all those patients who enter the ED with a diagnosis of asthma, shortness of breath, cough, wheeze, and dyspnea. Then further stratify your patients by their ED and outpatient charts and you will eliminate those with a primary diagnosis of CHF or pneumonia. We also stratify our patients based on their need for specialist and self-care.

Program Description
Initially, we collected data on one particular ED with a higher than average utilization by asthmatics and COPD patients and identified approximately 150 asthma and COPD visits per month. We discovered that 24% of these patients did not have primary care physicians to manage their care. Our conclusion was that 24% utilized the ED as their primary care. From this data collection and analysis, we sought input from physicians and administrators in developing our program goals. We further stratified ED patients who were over 17 and under 80 years old and had been diagnosed with either asthma or COPD. We developed a high-risk list registry of asthma and COPD patients, which significantly improved all of our case management programs. The goals were to improve patient care in order to meet national standards, decrease the percentage of patients without primary care physicians, decrease ED utilization by improving self-management, and improve quality of life.⁴

We also looked for decision drivers that would assist in marketing our program to administrators for financing our pilot. An important decision driver, Health Plan Employer Data and Information Set (HEDIS), is a report card of how well health care systems provide care for particular disease states, such as asthma (DRG 88). Companies that purchase health insurance for their employees can then compare several health care plans based on similar data. HEDIS measures persistent asthma including at least one of the following occurrences within the last year: dispensing four asthma medications; one ED visit; one asthma hospitalization; four outpatient visits for asthma along with two or more asthma medication dispensings.⁵

Another decision driver was the cost of providing ED care. This care was identified by billing processes and by benchmarking national data. Stanford et al⁶ benchmarked the national average cost of an ED visit for asthma as $210 (under 45 years old), while the cost of an asthma hospitalization was $2,731. By taking the cost of an asthma (or COPD) ED visit and multiplying it by the number of visits, the cost of providing ED care can be calculated. Of course, you should use your own ED costs in this calculation, identified by each individual billing department.

Pilot Program
While developing a proposal for a pilot program that focused on two different EDs, we established measurable objectives. Additionally, we looked for start-up resources, both internal and external. Boehringer Ingelheim assisted with case management expertise and supplies during our start-up phase. Outcome measurements included utilization of the ED, physician office visits, pharmacy utilization, and compliance with medication regimen. Other outcome measurements included patient satisfaction through self-management of their disease, primary care physician satisfaction, and the number of patients with primary care physicians. By focusing on adherence to our asthma or COPD clinical practice guidelines, including asthma action plans and COPD action plans, improvements in compliance with HEDIS 3.0 for DRG 88 (asthma) can be measured.

Outcomes measures
There are six basic outcomes measurements for case management. These include utilization, functional status, satisfaction, adherence to therapy, self-management behaviors, and cost analysis. It is very important to define outcome measures prior to starting a case management program. It is also recommended to decide how to measure outcomes and actually try to measure them, as we found some outcomes are very difficult to actually measure.

Utilization is defined by your targeted outcome measure. Some examples include ED visits, doctor office visits, unscheduled health care visits, hospitalizations and hospital length of stays, and pharmacy refills. In our pilot program, we chose ED and hospital utilization for this measure. We documented that physician office or clinic visits and ED visits decreased by measuring visits 12 months prior to case management compared to visits 12 months after case management by reviewing each chart. With only 16 hours per week (0.4 full time employees [FTEs]), we could not see all the ED patients, so we collected data on a randomized control group of similar patients; however, the success of this small pilot project resulted in expanding our program to 1.5 FTEs in 2001. Our initial results are listed in Table 1.

Reviewing the literature can provide a wealth of information when evaluating the cost and utilization measures for case management. From a cost perspective, respiratory therapy wages are less than nurse or pharmacist wages, which decreases the labor or costs of case management. This is an advantage in the cost projections for a case management program.

Functional status can be measured in self-reported data such as work or school days missed or the number of patients who quit smoking. More sophisticated quality of life measurements can be utilized—measurements that are validated by scientific research. Examples of these measurements include SP36, ATAQ, Juniper, and St George’s survey tools. We chose the Asthma Therapy Assessment Questionnaire survey to measure quality of life.^7,8 Our initial data were positive in terms of effects on patients’ daily lives. From my perspective, the two most important outcome measures are quality of life and utilization data as it relates to the cost of care.

Satisfaction can be measured by surveying both the patient and physician perspectives. Surveys can be done informally and reported as anecdotal data, but formal surveys will be more acceptable for quantification. Our survey data are very positive, but the anecdotal, informal feedback by both patients and clinicians is the most rewarding for case managers. Comments such as “I thought I was doing the best I could,” and “I can’t believe how much you’ve changed my life” are true job satisfiers for the case manager.

Adherence to Therapy
Adherence to therapy is an important, yet difficult outcomes measure. Adherence is defined as the degree to which patient behaviors follow the recommendations of health care providers. It is important for case managers to understand that even with careful, simple explanations of the reasons for taking medicines or changing behaviors, this will not equate to the patient following directions.

Adherence requires tracking each patient’s prescriptions. Do not make the mistake of simply tracking which medications they order, but more important, track the individual patient’s prescription refilling patterns. Patients will often selectively refill medications such as beta agonist bronchodilators but not refill anti-inflammatory medications such as inhaled corticosteroids. HEDIS measures include all patients with four or more beta agonists in a year and the number of controller drugs such as corticosteroids.⁴

Another useful measure is the beta agonist to corticosteroid ratio, which provides at a glance the level of control your asthma patients have obtained.⁹ The goal should be less than four to six beta albuterol inhalers per year for the asthmatic patient. As most therapists know, the mortality for asthma has been increasing for more than 10 years. An asthmatic patient using more than eight albuterol inhalers per year is at risk for ED visits or hospitalization and those using more than 16 albuterol inhalers per year are at risk for death.⁹

Nonadherence is not unique to asthma. In fact, only half of patients with chronic diseases take their medications as prescribed.¹⁰ In my experience, asthma patients tend to exclude their controller medications but often continue their beta agonists, probably because they immediately feel the effects. Common excuses for not taking their medications include “I forgot,” “I don’t have time,” “But I feel fine,” “I don’t need it,” “I’m afraid I’ll become addicted,” and “I don’t think it works.”

Nonadherence patterns in COPD are similar to those in asthma, which is typical in older age groups. Reasons for missing medications include “I felt good and decided not to dose,” “I felt good and forgot to dose,” “I got absorbed in an activity and forgot,” “I was interrupted prior to dosing and forgot,” “I had a change in my normal routine,” I don’t like the side effects,” and “I ran out of medicine.”¹⁰

Strategies to improve patient adherence to their care plan include establishing a personal relationship or partnership that creates an environment where the patient feels safe and comfortable to discuss their fears, concerns, and what personal goals are important to them. Do not lecture them. You have to really listen to what the patient says and focus on open-ended questions that allow them to talk. Educational opportunities at every health care visit should increase and reinforce the patient’s knowledge about their disease. For example, review inhaler techniques at every ED visit, doctor office visit, pharmacy refill, and case management encounter.

Of course, the asthma action plan and COPD action plan are essential strategies to aid patients in self-managing their disease. Our action plans follow the NAEPP pattern of green, yellow, and red zones.¹ It is common for patients to “lose” their action plans and forget the contents. We use both a wallet card and an electronic medical record, which allows clinicians or advice nurses in any of our clinics to access the patient’s action plan and print out a copy prior to discharge. Multiple reinforcement to following their action plan for self-management is important in patients’ education and adherence to therapy.

Learning to recognize and identify an individual patient’s adherence patterns and nonadherence behaviors is essential to successful case management. This will substantially improve your value as a case manager.

Marketing a Program
Marketing a program is the sales portion of starting and continuing a program. Initially, utilize evidence-based medicine by researching the medical literature for descriptions of successful asthma and/or COPD case management programs.¹¹ There is a wealth of information available that can be obtained through Internet searches on medical literature Web sites.

Legality issues should be addressed early in the process of developing a case management program. Review the state licensure act and scope of practice to ensure it is legal for respiratory therapists to provide case management via approved protocols. Explore community standards for respiratory therapy practice and ensure prudent delegation by physicians to respiratory therapists. Clearly identify safeguards to assure patient safety and physician support. Define how physician orders for case management are documented and communicated, as well as therapist orders under protocols. Also, develop an easy and effective communication plan between the RCP case manager, primary care physician, and specialty physicians such as pulmonologists and allergists.

I believe that RCPs are ideal asthma and/or COPD case managers. They have the formal training and competencies to work with this challenging group. But RCPs must also develop new skills in pharmacologic management, psychosocial assessment, care coordination, and communication in the outpatient culture. With preparation and planning coupled with outcome measures, the RCP can be a valuable asthma and COPD case manager.

Joe Dwan, MS, RRT, is director of respiratory care services at Kaiser Permanente Northwest Region, Clackamas, Ore.

References
1. Guidelines for the Diagnosis and Management of Asthma Expert Panel Report II. National Asthma Education and Prevention Program; 1997. NIH 97-4051.
2. Strassner L. The ABCs of case management: a review of the basics. Nursing Case Management. 1996;1:22-30.
3. Miller W. Motivational Interviewing, Professional Training Videotape Series. Albuquerque, NM: The University of New Mexico; 1998.
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5. Glauber J. Does the HEDIS asthma measure go far enough? American Journal of Managed Care. 2001;7:575-579.
6. Stanford R, McLaughlin T, Okamoto LJ. The cost of asthma in the emergency department and hospital. Am J Respir Crit Care Med. 1999;160:221-225.
7. Vollmer WM, Markson LE, O’Connor E, et al. Association of asthma control with health care utilization and quality of life. Am J Respir Crit Care Med. 1999;160:1647-1652.
8. Vollmer WM, Markson LE, O’Connor E, Frazier EA, Berger M, Buist AS. Association of asthma control with health care utilization. Am J Respir Crit Care Med. 2002;165:195-199.
9. Mendoza G. Diagnosis and treatment of asthma. Paper presented at: Oregon Society for Respiratory Care Annual Pacific Northwest Conference; February 2, 2001; Eugene, Ore.
10. Dolce JJ, Crisp C, Manzella B, Richards JM, Hardin JM, Bailey WC. Medication adherence patterns in chronic obstructive pulmonary disease. Chest. 1991;99; 837-841.
11. Im J. Evaluating the efficiency of asthma/COPD case management programs. Calif J Hosp Pharm. 1993;7:12-16.
12. American Association for Respiratory Care. Respiratory Therapist Human Resources Study—2000. San Antonio: American Association for Respiratory Care; 2000.