Table of Contents

• About this manual
• Background
• Disparities in health care
• Barriers to care
• Yes We Can program philosophy
• Elements of the YES WE CAN approach
• The Chronic Care model
• System change
• Clinic change
• In the real world

• Population management
• Medical risk criteria
• Social and Psychological risk criteria
• The Risk Stratification Pyramid
• Level 1: Self-management support
• Level 2: Basic case management
• Level 3: Moderate case management
• Level 4: Intensive case management
• Targeting the right population for level 2 and level 3 interventions
• Levels of care, target populations, goals and interventions table

• Overview of the Medical/Social Model
• The Care Pathway
• Family-Centered Care
• The Asthma Team

• Asthma clinic background
• Identifying the patients
• Establishing criteria
• Referral criteria
• Exclusion Criteria
• Gaining consensus from your community
• Getting the word out
• Referral sources
• Emergency Department and hospital linkages
• Computer generated high risk lists
• Screening referrals
• Inviting families to participate in the asthma program
• Emergency Department visit and hospital discharge follow-up
• Before the first appointment
• Appendix:
A Checklist for Screening Referrals
Welcome letter for the family
Brochure for families

• Overview
• Care path
• Asthma clinic overview
• Home visit overview
• Telephone assessment calls
• Self-management education
• Possible indications for specialist consultation

• Overview
• Goals
• Getting Started: Initial Planning and Set-Up for Asthma Clinic
• Weekly Asthma Clinic Prep
• Asthma clinic model: Table of key features
• Initial asthma clinic visit patient flow
• Return asthma clinic visit patient flow
• Conclusion

• Background
• Home Overview

• Overview
• Tools
• Timing and frequency of calls
• The Goals of Telephone Assessment Calls
• Documentation
• Telephone Skills
• Before the call
• Set the stage
• Elicit questions and concerns
• Discuss progress on goals
• Assess current asthma control
• If Asthma is Not Controlled, Why Not?
vAssess readiness for behavior change
• Assess self-efficacy
• Summarize and Discuss Next Steps
• After the Call
• Appendix
• Example script
• Telephone Assessment Form
• Telephone Assessment Protocol

• Exit criteria
• Successful completion or graduation
• Families that "opt out"

• Overview
• The Three Phases of Case Management
• Components of a care plan
• Developing a care plan
• Prioritizing problems
• Problem solving
• Community resources
• Appendix:
• Examples of a care plan
• Practice activity #1: Take a walk in your family’s shoes
• Practice activity #2: Develop a care plan

• Self-management education vs. patient education
• Collaborative Care
• The family’s role in a collaborative partnership
• Assess the needs of the family
• 12 Tips for communicating effectively in a health care setting
• 12 Tips for providing effective self-management education
• Key educational messages
• Introduction to self-management education protocols
• Protocols for providing self-management education (includes patient handouts):

General guidelines

What is asthma?
Long-Term Control Medications--Inhaled Corticosteroids
Long-Term Control Medications--Bronchodilater
Long-Term Control Medications--Long-Acting Bronchodilator: Theophylline
Long-term Control Medications--Leukotriene Receptor Antagonists (LRTA)
Long-term Control Medications--Cromolyn Sodium and Nedocromil Sodium
Quick-Relief Medication--Albuterol
Quick-Relief Medication--Anticholinergics
Peak Flow and Symptom Monitoring
Finding the personal best peak flow
Understanding asthma action plans
Correct use of a metered dose inhaler and spacer device
Correct use of a dry powder inhaler
Medication: Reading prescription labels and getting refills
Medication: Tracking puffs in a canister
Identifying and controlling asthma triggers
Recognizing and Managing Severe Asthma Episodes
Physical activity/Exercise and asthma

• Documentation of Self-Management Education

• Using the Asthma Self-Management Education Checklist

• Appendix:
Self-management education checklist
Key messages for families living with a chronic condition
Key messages for families living with asthma

• Introduction
• Background
• What Is Behavior Change Counseling?
• Brief Negotiation Communication Guidelines