Pediatric Allergy and Immunology, Department of
    Pediatrics,
    Pasquerilla Healthcare Center, Second Floor, Georgetown
    University Hospital, 3800 Reservoir Road, N.W.,
    Washington, D.C. 20007, 202-444-4904,
    www.georgetownuniversityhospital.org

    Children's National Medical Center: Allergy &
    Immunology,  
    111 Michigan Avenue, NW Washington, DC 20010, 202-
    476-5000, www.dcchildrens.com  
                    Improving Pediatric Asthma Care in the District of
    Columbia (IMPACT DC)/Asthma Education Program

    IMPACT DC is a pediatric asthma surveillance, research
    and intervention project located at Children’s Hospital and
    the Children's Health Project located in the Town Hall
    Education, Arts and Recreation Campus (THEARC).

    The mission of IMPACT DC is three-fold:

        * Rigorously track and characterize the epidemic of
    uncontrolled pediatric asthma within the District of Columbia
        * Study novel and translational means to intervene in the
    epidemic
        * Disseminate evidence-based best practice nationwide

    IMPACT DC is the honored recipient of the 2006 National
    Leadership Award in Asthma Management from the United
    States Environmental Protection Agency (EPA).

    IMPACT DC is featured on www.pediatricasthma.org, a new
    web site sponsored by the Robert Wood Johnson
    Foundation and is a member of the National Capital Asthma
    Coalition.

        * Vision: Interventions to Improve Education and Care
        * Services Provided
        * History of Impact DC

    Vision: Interventions to Improve Education and Care
    The vision of IMPACT DC begins with the notion that
    effective longitudinal asthma care is a broad continuum that
    involves many parties. At the center of this model is the
    patient who interfaces with his/her family, primary care
    physician (PCP), hospital, emergency department (ED),
    retail pharmacist, insurance case manager, and school
    nurse.

    The ED can and should be a critical and integral part of this
    continuum, particularly for children who use the ED frequently
    and are poorly connected with PCPs and other sources of
    care.

    VIDEO THUMBNAIL Video: Asthma…research that helps
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    Intervention
    The IMPACT DC Asthma Clinic is a unique ED-based
    asthma care source that operates continuously at Children’s.
    It sees children who are heavily dependent on EDs for
    episodic care, providing a comprehensive source of asthma
    education, medical care and care coordination designed to
    steer children towards healthier lives and more effective
    primary longitudinal asthma care.

    The clinic sees children within two weeks of ED visits for
    acute exacerbations for a 90-minute visit where they meet
    with an asthma educator and a physician. While highly
    individualized and based on a shared dialogue with the
    family and the patient, the clinic’s curriculum is well scripted
    and highly reproducible. Taking advantage of the “teachable
    moment” that naturally occurs after the crisis of an ED visit,
    clinic staff focus on the three key elements of the consensus
    guidelines for asthma care developed by the National
    Institutes of Health:

        * Medical Care
              o Education on the basic physiology of asthma with
    emphasis on its chronic nature
              o Completion of an individualized medical action plan
              o Prescription of controller medications, as indicated
    by protocol
              o Device teaching (spacer, diskus, nebulizer), as
    indicated
              o Education on self-monitoring (by symptoms and/or
    peak flow measurement)
              o Provision of a peak flow meter and/or spacer, as
    indicated
        * Environmental Modification/Trigger Control
              o Education on the role of the environment and
    triggers in asthma
              o Specific education on the creation of a “safe sleep
    zone”
              o Provision of pillow covers
              o Tailored education on the following, as individualized
    for the family:
                    + Tobacco smoke
                    + Dust
                    + Molds
                    + Pests
                    + Pets
        * Care Coordination
              o Education on the role and importance of longitudinal
    asthma care with a primary care provider

    Services Provided
    The multiple activities of the IMPACT DC Asthma Clinic are
    valuable in themselves, but coordination with primary care
    physicians (PCPs) and others in the care continuum is
    among the most crucial. This linkage between the ED and
    these caregivers represents an expanded role for the ED in
    which its activities are seen in the context of the broader
    systems of care for chronically ill children. To achieve such
    care coordination, we provide multiple services designed to
    improve and strengthen linkages between all those
    providing asthma care for the child. These activities include:

        * Creation of an individualized patient report (with an
    embedded digital photograph of the child) that is forwarded
    to the patient’s primary care physician, managed care
    asthma case manager and school nurse via fax and/or mail,
    as well as to the patient and family
        * Direct phone communication between the clinic
    physician and PCP when required
        * Scheduling of a follow-up PCP appointment within 4
    weeks of the clinic visit
        * Scheduling follow-up appointments with the PCP and, as
    required, with sub-specialists who will provide further
    evaluation and treatment
        * Completion of school forms sufficient to allow child to
    receive reliever and controller medications in the school
    from the school nurse when appropriate

    Children’s program is uniquely positioned to facilitate care
    coordination by leveraging existing relationships, particularly
    the District’s School Nurse Program and the Goldberg
    Center for Community Pediatrics. In fact, Children’s employs
    all public school nurses through the school nurse program
    and provides the school nurse of each IMPACT patient with
    an individualized asthma care plan for use while at school.

    Similarly, for children without an identified primary care
    source, IMPACT works with financial counselors at Children’
    s to facilitate enrollment in Medicaid Managed Care.
    Through this process the team identifies a new primary care
    provider in Children’s healthcare system, which provides
    more than 50 percent of the primary care to Medicaid
    recipients in the District.

    The IMPACT team rigorously studied this model of care to
    validate its efficacy in a prospective randomized clinical trial,
    which was accepted for publication in the Archives of
    Pediatrics and Adolescent Medicine, a JAMA publication.
    The study achieved several clinically and statistically
    significant outcomes:

        * Greater than 100 percent increase in the use of
    controller medications
        * Nearly 50 percent reduction in subsequent ED visits
        * Sustained improvements in numerous measures of
    quality of life

    The next goal is to refine and to expand the trial, bringing
    even more partners into the process of reducing asthma
    morbidity among disadvantaged children.

    History of IMPACT DC
    IMPACT DC was founded in the fall of 2001 with funding
    from the Robert Wood Johnson Foundation to perform
    surveillance of pediatric emergency department visits for
    acute asthma exacerbations and to design and implement
    an intervention to address the problem in the District of
    Columbia. These efforts culminated in the creation of the
    IMPACT DC Asthma Clinic, a novel asthma follow-up care
    source physically located in the Emergency Department at
    Children’s.

    IMPACT DC serves as one of 10 sites of the Inner City
    Asthma Consortium (ICAC), which studies immune-based
    asthma therapies in children and young adults. The team
    collaborates with the Center for Genetic Medicine Research
    on the AsthMap Project, which characterizes the genotypes
    and phenotypes of more than 1,000 asthmatic children in the
    Washington, DC, metropolitan area. Finally, the program
    collaborates with local inner-city pharmacies to study the
    effect of enhanced asthma education by community
    pharmacists.
             
    Institute for Asthma & Allergy,11002 Veirs Mill Road,
    Suite 414, Wheaton, MD 20902, 301-962-5800;5454
    Wisconsin Ave., Suite 700 Chevy Chase, MD 20815, 301-
    986-9262, www.allergyasthma.us
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