National Asthma Control Initiative: Keeping Airways Open - Putting the Guidlines Implementation Panel Report in Motion

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Originally published by the National Heart, Lung, and Blood Institute (NIH Publication No. 10-7543). U.S. government work, public domain. Reproduced as archived reference, not current guidance.

Keeping Airways Open

Putting the Guidelines Implementation Panel Report in Motion

A Plan of Action for the National Asthma Control Initiative

Preface

Action Item 1: Convene leaders and stakeholders and energize them to become involved in NACI activities

Action Item 2: Develop a communication infrastructure to promote dialogue among stakeholders, give access to resources, and share information

Action Item 3: Encourage and support partnerships to enhance integration of clinical and community-based interventions and strengthen sustainability

Action Item 4: Fund and support best practices and evidence-based demonstration projects

Action Item 5: Monitor and assess NACI progress by using outcome measures and sharing lessons learned

Putting the Guidelines Implementation Panel Report in Motion

A Plan of Action for the National Asthma Control Initiative

http://naci.nhlbi.nih.gov

NIH Publication No. 10-7543

April 2010

Preface

Inhaling and exhaling—most of us don’t give it a second thought.

1 2

For the 23 million Americans who have asthma, including some 6.7 million children, breathing isn’t quite so simple. This common chronic disease often impacts physical, psychological, and social wellbeing and quality of life. Moreover, the financial costs of asthma, particularly for uncontrolled and poorly controlled asthma, are substantial both for individuals and for society. Overall, the economic burden due to asthma, ranging from hospitalizations to lost wages, has been estimated to be as much as $19.7 billion.

In Crossing the Quality Chasm (2001), the Institute of Medicine notes asthma as one of 15 “priority conditions” for which strategies, goals, and action plans should be developed to achieve substantial improvements in health care quality.

Now, thanks to a new initiative formed to prompt action on using the latest evidence-based national guidelines for diagnosing and managing asthma, we have an opportunity to help people who have asthma breathe easier.

You can make a difference in the lives of millions of Americans by joining forces in the new National Asthma Control Initiative (NACI). The NACI is an initiative of the National Asthma Education and Prevention Program (NAEPP), coordinated by the National Heart, Lung, and Blood Institute (NHLBI). NAEPP members include major scientific, professional, governmental, patient advocacy, and voluntary organizations working to enhance the quality of life for people with asthma and to decrease asthma-related morbidity and mortality.

The NACI will bring together organizations from local, regional, and national levels to share best practices; leverage resources; identify new directions; create learning opportunities; and ultimately bring the asthma care that patients receive in line with NAEPP’s national clinical practice guidelines.

This document outlines what action steps the NHLBI—as convener and as member of the NAEPP—is committed to undertaking in order to engage and stimulate further activity by partners and other stakeholders.

1. Pleis JR, Lucas JW. (2009). Summary health statistics for U.S. adults: National Health Interview Survey, 2007. National Center for Health Statistics. Vital Health Stat 10(240).
2. Bloom B, Cohen RA. (2009). Summary health statistics for U.S. children: National Health Interview Survey, 2007. National Center for Health Statistics. Vital Health Stat 10(239).
3. National Heart, Lung, and Blood Institute. (2007). Morbidity and Mortality: 2007 Chartbook of Cardiovascular, Lung and Blood Diseases. Bethesda, MD: U.S. Department of Health and Human Services.
4. Institute of Medicine. (2001). Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press.

4 Putting the Guidelines Implementation Panel Report in Motion

A Plan of Action for the National Asthma Control Initiative 5

A Roadmap for Change

For the past 20 years, the NAEPP has been working with government and voluntary agencies, professional associations, patient advocacy groups, and many other organizations to develop national clinical practice guidelines and to educate patients, health professionals, and the public.

To develop the guidelines, the NAEPP has convened expert panels to conduct a systematic review of the scientific evidence and provide recommendations for making appropriate clinical decisions about asthma care. The NAEPP released the latest panel report, Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma, in August 2007. It outlined four key components of asthma care, summarized briefly below.

Component 1: Assessment and Monitoring. To diagnose and assess the characteristics and severity of asthma and to monitor whether asthma control is achieved and maintained.

Component 2: Education. To build a solid partnership for effective asthma self-management education among the patient, family/caregiver, and health care provider.

Component 3: Environmental Control. To implement multi-faceted strategies to control environmental factors and to treat comorbid conditions that affect asthma.

Component 4: Pharmacologic Therapy. To select the appropriate medications and to review the patient’s technique and adherence to meet the patient’s needs and circumstances.

Nevertheless, simply knowing the components of asthma management is not enough. The challenge is to create an effective plan of action that integrates them—a plan that will bridge the significant gap between treatments proven to work and the level of care that actually is being received by many asthma patients. For instance, although prescribing of appropriate asthma medications by physicians has increased, many asthma patients do not take their medication or do not use it properly. Further, many patients and caregivers remain unaware of how to effectively manage asthma on a daily basis and how to respond to asthma attacks.

6 Putting the Guidelines Implementation Panel Report in Motion

To help meet the challenge of fully implementing the guidelines, the NAEPP convened a diverse 17-member Guidelines Implementation Panel (GIP) and charged it with developing a report to enhance the implementation of the EPR-3 guidelines. The GIP identified six priority, action-oriented messages within the four components of asthma care outlined above:

• Use Inhaled Corticosteroids (Component 4)
• Use Asthma Action Plans (Component 2)
• Assess Asthma Severity (Component 1)
• Assess Asthma Control (Component 1)
• Schedule Followup Visits (Component 1)
• Control Environmental Exposures (Component 3)

Within each of these six messages, the GIP Report grouped its recommendations and strategies around three core themes. The GIP identified these themes as being associated with successful health care interventions, and as providing a useful structure for organizing numerous GIP recommendations and strategies to support a nation-wide program for improving guidelines implementation.

The three themes are:

1. Communication. Getting the messages out on a broad scale to all audiences, including patients and providers, in a variety of settings.
2. Systems Integration. Designing and coordinating messages for essential players up, down, and across the operational tiers of a health system as well as across multiple systems; and strengthening linkages between health and community systems.
3. Patient/Provider Support. Identifying the tools, techniques, and other resources that would enhance guidelines implementation.

The GIP Report envisioned three overarching implementation approaches, or “effector arms,” all simultaneously working to move the document from a static set of recommendations and strategies to a dynamic, integrative, and comprehensive mobilization effort.

1. NAEPP Partnerships. Stimulate and coordinate NAEPP initiatives, partnerships, and collaborative activities to facilitate implementation of the GIP recommendations.
2. National Asthma Campaign. Develop, implement, and evaluate a coordinated national asthma campaign to cultivate new stakeholders and educate stakeholders about the six priority messages using NACI branded materials.
3. National Asthma Policy Forum. Convene a national forum that would feature expertise in public health and health policy and promote the implementation of policies that advance the EPR-3 guidelines.

A Plan of Action for the National Asthma Control Initiative 7

The GIP Report gives guidance to all asthma stakeholders for taking action around the six priority messages. While the NAEPP coordinated the development of the GIP Report, the NAEPP, through its partnerships and collaborative activities, is only one of the three effector arms identified by the GIP Report to stimulate the implementation of its recommendations and strategies (see Figure 1). To this end, the NAEPP, supported by the NHLBI, is focused on enhancing partnerships and collaborative activities through a new initiative, the NACI, to fuel initial and sustainable momentum among asthma stakeholders for implementing the GIP Report. Although the NACI is focusing initially on the partnership effector arm, it will work collaboratively with other effector arms to enhance implementation of the six priority GIP messages.

Figure 1: National Asthma Control Initiative Framework

NAEPP

NACI Action Items

EPR-3 Guidelines Implementation through

broad-based stakeholder Develop a communication engagement Convene and energize infrastructure for information national, regional, state, sharing and accessing and local leaders resources Six GIP Messages National Asthma Campaign

1. Use inhaled corticosteroids GOAL Improved asthma
2. Use written asthma care, asthma action plans control, and quality of life for all people
3. Assess asthma severity NAEPP/NACI with asthma Partnerships and Monitor and assess Mobilize champion Activities NACI progress toward networks to implement
4. Assess and monitor its goals by measuring and integrate clinical asthma control outcomes and sharing and community-based lessons learned interventions with emphasis on
5. Schedule followup visits sustainability National Asthma Demonstrate evidence-based
6. Control environmental and best practice approaches Policy Forum exposures for specific audiences in various settings with emphasis on closing the asthma disparity gap
7. National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program. (2007). Expert Panel Report 3 (EPR3): Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: U.S. Department of Health and Human Services.
8. National Committee for Quality Assurance. (2004). The State of Health Care Quality: Industry Trends and Analysis. Washington D.C.: National Committee for Quality Assurance.
9. Lara M, Rosenbaum S, Rachelefsky G, et al. (2002). Improving childhood asthma outcomes in the United States: a blueprint for policy action. Pediatrics, 109(5): 919-30.
10. National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program. (2008). Guidelines Implementation Panel Report for Expert Panel Report 3 - Guidelines for the Diagnosis and Management of Asthma. Bethesda, MD: U.S. Department of Health and Human Services.

8 Putting the Guidelines Implementation Panel Report in Motion

The Highway Ahead

The road to implementation may be long and winding, but over every hill and around every bend are incredible opportunities for collaboration and innovation. With the GIP’s guidance on how to implement the latest evidence-based guidelines, and the participation and assistance of multiple stakeholders in the NACI, we can overcome dynamic behavioral and systemic barriers. NHLBI is committed to five overarching action items based on the GIP Report to set the NACI in motion:

Action Item 1. Convene leaders and stakeholders and energize them to become involved in NACI activities. Action Item 2. Develop a communication infrastructure to promote dialogue among stakeholders, give access to resources, and share information. Action Item 3. Encourage and support partnerships to enhance integration of clinical and community-based interventions and strengthen sustainability. Action Item 4. Fund and support best practices and evidence-based demonstration projects. Action Item 5. Monitor and assess NACI progress by using outcome measures and sharing lessons learned.

The NACI Plan of Action is a framework to be used in tandem with the GIP Report, which offers more detailed recommendations and strategies for activities and interventions to improve asthma control. Moreover, it is designed to be a living document; as progress is made or issues emerge, the NACI will modify its approaches accordingly.

Although one agency cannot possibly address all of the recommendations and strategies outlined in the GIP Report or in this Plan of Action, the NHLBI is committed to providing a launching pad and several focused activities to build momentum for the NACI. However, it will take the involvement of many stakeholders across the asthma community and beyond to reach the objectives presented in the GIP Report. NHLBI invites organizations and individuals to join in these initial activities, and to take on other recommendations and strategies outlined in the GIP Report. It is through such collaborative and synergistic linkages that the NACI hopes to foster increased adoption of the evidence-based best practices reflected in the six priority GIP messages.

A Plan of Action for the National Asthma Control Initiative 9

10 Putting the Guidelines Implementation Panel Report in Motion

Action Item 1:

Convene leaders and stakeholders and energize them to become involved in NACI activities.

The GIP Report calls for stakeholders at all levels to “get involved” with implementing six priority messages derived from the EPR-3 Guidelines. Multi-sector stakeholder activities can bring about high-impact solutions and meaningful change across the spectrum of issues and barriers that impede effective asthma control. The NACI will engage NAEPP Coordinating Committee members and other traditional stakeholders and will recruit new partners to be “conveyors” and “navigators” of the GIP messages. This expanded and energized partnership of asthma champions will promote enhanced communication about the messages, integrate the messages into health systems, and increase awareness about supportive tools and materials available to enhance patient/family and provider behavior to improve asthma control. The enthusiasm and energy of the asthma community is high; the NACI will build on this to create a movement around the GIP messages as a significant means of improving asthma control.

• Identify and recruit partners from diverse sectors and disciplines who have the ability to make an impact on implementation barriers and who have access to and influence target audiences. Examples of sectors to engage include: - Government agencies - Professional associations - Patient advocacy groups - Academic institutions

• Engage partners in direct dialogue around important NACI issues (e.g., patient self-management, care coordination, quality improvement, reimbursement, health benefits, public health policies) to facilitate partner engagement. - Identify common and complementary interests and capabilities. - Further define partner roles and what each partner will do to support the work of the NACI.

• Asthma coalitions
• Bring partners together to share lessons, mobilize
• Media resources to respond to issues of mutual concern,
• Employers and create and maintain widespread support for
• Schools and childcare centers the GIP priorities.
• Clinical systems of care, including
• Develop a unifying logo and tagline to promote hospitals, health plans, and community a pervasive awareness of the scope of the health centers NACI and emphasize its value among multiple
• Payors stakeholders.
• Medical/nursing training programs
• Develop tools and materials to aid in building
• Faith-based organizations support for the NACI, such as slide show templates and fact sheets about the initiative.

A Plan of Action for the National Asthma Control Initiative 11

Action Item 2:

Develop a communication infrastructure to promote dialogue among stakeholders, give access to resources, and share information.

It will be essential to establish a communication infrastructure that can accommodate the diverse needs of NACI partners and stakeholders and enhance communication with patients and the public. A planned, coordinated infrastructure will help to develop and foster collaboration and information sharing among partners, and to monitor progress on the various GIP implementation-related activities. In developing a communication infrastructure, when possible, the NACI will work within existing communication networks to minimize duplication of efforts and to maximize reach.

• Develop a Web site. An Internet presence for
• Facilitate the development of “communities the NACI is vital to keep stakeholders abreast of NACI activities and engaged in the initiative. The Web site will serve to facilitate communication among partners involved in asthma activities who may have limited opportunities or forums in which to discuss their efforts, to collect information from NACI participants about their activities, and to house and distribute information and tools identified and/or developed by NACI stakeholders.

of practice” organized around GIP messages, target audiences, or program settings. Communities of practice may be formal subcommittees of the NAEPP Coordinating Committee, or they may be informal groups that network primarily online and through e-mail listservs. Moreover, some groups may be “seeded” by the NACI, while others will develop organically. Whatever the case, it is expected that these groups will make the full use of online and offline networking tools to share information and resources, promote collaboration around issues of mutual interest, and identify gaps in the implementation of the GIP recommendations.

Putting the Guidelines Implementation Panel Report in Motion

Action Item 3:

Encourage and support partnerships to enhance integration of clinical and community-based interventions and strengthen sustainability.

Interventions promoted by the NACI should be guidelines-based and intended to promote changes in patient and/or provider behavior and in health care systems to enhance quality of care, improve outcomes, and reduce health disparities. At every level of intervention, the key to mobilizing support around this issue will be the recruitment and establishment of asthma champions who are committed to improving care, promoting the EPR-3 guidelines in their workplaces and communities, and fostering collaboration between clinical and community care structures.

Among the many places that champions can implement clinical and community-based interventions are rural and urban areas, medical and nursing schools, medical practices, workplaces, insurance and benefits companies, school systems, state and local public health departments, asthma coalitions, and community - and faith-based organizations.

• Identify and recruit partners from diverse sectors and disciplines who have the ability to make an impact on implementation barriers and who have access to and influence target audiences. Examples of ways that champions can access and influence target audiences include:

management efforts while facilitating integration of activities among various levels of the care system (providers, patients and families, schools, communities). - Adopt or develop NACI-branded tools and resources for use by champions, health care providers, patients, and their families.

• Support the adoption of GIP recommendations
• Develop approaches (including case and strategies by offering a menu of resources management programs) that promote patient and interventions that could be implemented self-management skills and provider by champions in diverse settings, including communication techniques that are culturally clinical and community environments. relevant, easily understood and accepted
• Use lessons learned and tested tools from by patients and their families. quality improvement strategies and pointof-service prompting (e.g., electronic health

records, pay for performance, standing orders, provider feedback, and plan-level quality measures) to enable improvements in clinical and public health practices. - Work with partners to develop online asthma management tools that could be used in existing medical information systems. Such tools would improve the tracking of asthma

• Encourage champions to document the scope, reach, and impact of their programs and to share this information through the NACI. In addition, champions will be encouraged to exchange tools, materials, and other best practice approaches. • Build programs and interventions in ways that will sustain the involvement of asthma champions and other stakeholders.

A Plan of Action for the National Asthma Control Initiative 13

Action Item 4:

Fund and support best practices and evidence-based demonstration projects.

The NHLBI will stimulate the implementation of the demonstration projects funded by competitively awarded contracts to serve as testing grounds for further exploration and real-world insight into promising practices to enhance asthma control. Applications will be sought from institutions looking to promote GIP messages in new ways, as well as institutions taking proven interventions into new communities or settings. Funded demonstration projects will comprise one tier of partners integral to the composition of the NACI.

• Establish an “Enhanced Application Projects” contract program to support NACI demonstration projects. The purpose of this program is to promote the implementation and dissemination of science-based asthma strategies and interventions. • Solicit proposals that address one or more

• Track and assess project implementation through the collection and analysis of process and outcomes data. • Use the national communication infrastructure to disseminate lessons learned and findings from the demonstration projects during and after implementation. of the six GIP messages, focusing on the target audiences and strategies appropriate to the applicant institution.

• Issue awards to fund selected demonstration projects.

14 Putting the Guidelines Implementation Panel Report in Motion

Action Item 5:

Monitor and assess NACI progress by using outcome measures and sharing lessons learned.

Evaluation of NACI activities will strive to balance the need to be rigorous with the need to be realistic and practical and will use appropriate methods to ensure meaningful and defensible results. Evaluation should also consider contextual factors that may influence the success of particular implementation strategies.

Assessment and measurement will be designed to:

• to provide quality data that will help the NHLBI and its partners to continually improve the program
• to use for future scale-up of program components
• to highlight the reach, output, and impact of the program to key constituencies

reach and impact of NACI demonstration projects,

• Develop a logic model to articulate the overall strategic partnerships or the champions program: goals and objectives of the NACI as well as describe individual program activities with expected outputs and outcomes.
• Engage stakeholders in the evaluation process and frame evaluation questions to be of use

gathering process and outcomes data and using this information to highlight successes and help improve projects. Consider ways to integrate common measures to stakeholders.

• Focus the evaluation design to employ an appropriate choice of practical evaluation

that would allow for pooling of data across interventions. methods that address the key research questions while being mindful of the audience and setting under examination. For example, research questions may assess how NACI resources are being used globally, and how they may look at specific components of the NACI, such as the

A Plan of Action for the National Asthma Control Initiative

reporting and dissemination plans.

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NIH Publication No. 10-7543

April 2010