Chapter 12
Illustrative patient pathway to self care: asthma

This chapter gives you an example of a practice team’s approach to the self care of asthma.

Section 1 Self care for asthma

The start

We start from a patient’s perspective. You could:

work through the detailed scenario observing the sort of issues and discussion that the fictional practice team progress through here
discuss how your team would respond to the patient story given here
take an example case of a patient with asthma from your own practice (anonymising the patient’s identity in the team’s discussion as appropriate).

If you feel that you do not knowenough about the management of asthma to complete the problem based learning, learn more about the range of self care support options and read through the clinical summary about asthma in the second section of this chapter before you start the problem based learning exercise.

Patient’s story 12.1

‘I have recently moved house and registered with another health practice. This one seems more interested in supporting people like me to look after themselves better.

Before I met with the asthma nurse for the first time, I had only been to one asthma clinic at my last practice. This was probably partly my fault as I was reluctant to go there unless I was ill and I did not think that my asthma was severe enough to warrant getting time off work just for a check up. The practice I am with now sends me an invitation to make an appointment to review my asthma. The letter acts as a reminder. It makes me feel that I am not wasting their time by going when I’m not ill.

It wasn’t until my first appointment with the new practice that I realised what a messmy asthma was in. I had no control over it andmust have got used to living with it that way. The nurse got me to do a peak flow reading and asked a variety of questions which led to the conclusion that I was not using my inhalers properly. The nurse prescribed a spacer for me, explained how to use it and which inhaler to use with it, and askedme to try this for about a month and a half. While I was there, the nurse made an appointment for me to go back so she could monitor my progress.

After a few visits to see the nurse, I was able to report that my asthma had improved a lot and I was much more in control of it. This has made such a difference to my quality of life. The nurse filled in a plan for how I could take care of my asthma in future, which I took home with me. I can look at my self care plan on the card when I’m not sure what to do.’

Note: the patient in this scenario had needlessly awaited resolution of and tolerated the symptoms, and after coaching can do self care for their asthma to relieve the symptoms and prevent it worsening.

Your project team

Consider Tool 11 on team building

You might want a team to discuss alternative self care support options for asthma as in this example, to include:

reception staff
practice manager
GPs
practice nurses
health care assistants
practice-based pharmacist
district nurse
patient representative
physiotherapist
practice secretary.

You could use a checklist as in Table 12.1 (see p. 151). to record who is involved and in what way.

Team discussion considering the patient story 12.1

Consider Tools 1, 3, 4, 5, 6, 8 or 10 for your teamwork and discussions

In this scenario, discussion between the fictional practice team members reveals:

the pharmacist is keen to be involved in supporting self care of asthma. She has been concerned about the high level of symptoms she hears about and the number of people who appear to be using reliever inhalers without preventer inhalers. She would like to be involved in asthma reviews, but is worried about the time involved
the doctors and nurses manage asthma following the British Thoracic Society and SIGN guidelines (or in the USA those from the National Heart Lung and Blood Institute’s Practical Guide for the Diagnosis and Management of Asthma) but concordance with treatment is poor1–3
practice nurseswho have been trained in asthmamanagement are still catching up with making sure all the people using inhalers have a diagnosis of asthma or chronic obstructive pulmonary disease (COPD). They have insufficient time to educate people about asthma or how to take care of it themselves
health care assistants would like to be involved in asthma management but lack training. The nurses feel that they do not have time to do any training
receptionists involved in repeat prescriptions complain that doctors give further prescriptions to patients on repeat medication for inhalers even when they have ignored requests to come for review
receptionists feel anxious about how they should deal with patients who need help with acute asthma
the district nurse complains that patients who are housebound are not receiving the same reviews as those able to attend the surgery
the patient representative feels patients are made to feel that they must ask the experts how to take care of their asthma. He feels that a small panel of patients who have experience of undertaking self care for their asthma could help educate others
the physiotherapist sends a message to say that she is unable to see people with asthma breathing dysfunction as she has insufficient appointment time
the practice manager is concerned about the wasted time in asthma clinics when people do not attend. The practice secretary feels that the practice nurses should be responsible for recalling patients to the asthma clinic and it wastes secretarial time sending out appointments that are not kept.

What you do next might include:

Consider any of Tools 2, 3, 4, 5, 6, 7, 8, 9 or 10 for your action planning

arrange a meeting for the members of the project team to look at ways that patients can be educated about prevention of attacks following their self care plans
the practice manager and practice nurses agree to consider how the health care assistants can extend their role to relieve the practice nurses of some of the recording work in the asthma clinic and of the time-consuming activity of teaching the use of inhalers
the practice manager will ask if the physiotherapist can come to the practice to teach the practice team about hyperventilation and how to control breathing
two receptionists will be trained to send patients a computer-generated letter explaining why review is necessary and inviting them to make an appointment instead of sending them a fixed appointment. A computer audit search will be done each month to identify the patients after the practice secretary has set this up from her present recall system
one of the GPs will form a small group of patient educators. He has recently been to a workshop about using patients as educators in registrar training and is enthusiastic to extend the principle. The aim will be to run regular meetings for people with asthma at a suitable venue, with minimal input from professionals
the practice manager will arrange a workshop for the receptionists to go through various clinical scenarios and learn the difference between the zones of control of asthma in patients’ self care plans
district nurses agree to have training from the asthma-trained practice nurses
the district nurses and the practice will negotiate with the district nurse manager for time to review housebound patients that they already visit, as the numbers are small
receptionists will compile a list of patients who are housebound but requiring review. The practice manager will approach a voluntary service that provides hospital and day care transport to see if these few people could be brought to the practice for review
the practice nurse will trial a buddying scheme, where newly diagnosed patients with asthma are paired with someone of similar age and background whose asthma was diagnosed a while ago and is under good control
the practice-based pharmacist and practice manager will approach the PCT to propose that patients with asthma are a target group for MURs by community pharmacists, as these reviews are paid for from the national pharmacy budget. The reviews will last about 20–25 minutes and focus on how patients are using medicines and their understanding of their treatment (e.g. asthma). These will be annual reviews with additional reviews as required.

What extra resources might this require?

Consider either Tool 8, 10 or 17 for determining resource and skill needs

Time for meetings and for training.
Protected time for the practice manager to arrange meetings and training, monitor and support the introduction of the changes.
Physiotherapist time to come to the practice to run an education session.
Protected time for the receptionists to operate the recall system.
Time for the GP to set up and support the patient educators and asthma group.
Longer appointments in the asthma clinic while the health care assistants are learning.
Extra time for the district nurses to review housebound patients that they visit.
Protected time and funds for the pharmacist to introduce asthma reviews, education and self care plans and liaise with practice nurses.
Time (and possibly training) for staff to implement, monitor and audit the project.
Additional staffing hours may be needed initially - achieved by modifying the workload or extending the hours of existing staff or employing additional staff.

The outcomes might include:

Either of Tools 9 or 12 will help to monitor progress

better and more confident self care of asthma (P, A, R, T) by patients (Prevent the condition, Await resolution, use self care for Relief of symptoms, learn to Tolerate symptoms) see Box 12.2, p. 153
fewer episodes of admission in those who are using the programme (P, A, R, T)
fewer inappropriate requests for GP appointments from patients with asthma that they could have avoided by doing self care (A, R, T)
improvement in management of all zones of asthma by patients (A,R,T)
fewer referrals to secondary care as there is better self care of asthma; concordance with treatment reduces the number and severity of attacks (P, A, R, T)
no failures to identify and seek help appropriately for deterioration in asthma control (A, R, T)
an active and useful support group for patients with asthma with expert input from those more experienced in its care (P, A, R, T)

How would you demonstrate that you have achieved your outcomes?

Consider Tools 9 or 12 for reviewing outcomes

Feedback (informal and formal) from patients about their self care of asthma, avoidance of triggers and confidence in monitoring their breathing patterns (P, A, R, T).
Comparison of consultation rates for asthma at the practice before and after the project (P, A, R, T).
Comparison of rates of review for asthma before and after the project (A, R, T).
Comparison of the number of patients with a written self care action plan before and after the project (A, R, T).
Comparison of emergency hospital admission rates for asthma before and after the project (P, A, R, T).
Comparison of number and types of referrals to secondary care for asthma before and after the project (P, A, R, T).
Self-rating and peer review of the effectiveness of education and use of written self care plans by nurses, pharmacist and GPs (P, A, R, T).
Significant event audit of any failures to identify the necessity for medical input for deterioration of asthma control (A, R, T).

Table 12.1:
Role and responsibilities checklist For each task tick the box for each team member who has a role or responsibility - then note your role and responsibilities for the task.

Role and responsibilities checklist

part 2

Chapter 12 Illustrative patient pathway to self care: asthma