shared decision making (sdm) materials

ACE STUDY

Asthma Comparative

Effectiveness

Shared Decision

Making (SDM) Materials

For use with patients

12 years & older

• Half Day Clinic Flow

• Spirometry Technique

• Documentation Template

• Initial Script

• Follow Up Script

• Form 1: Patient Information Sheet

• Form 1: Follow Up Patient Information Sheet

• Controller/Reliever Posters

• Form 2: Blank Control Dial

• Form 3: Treatment Goals and Medication Preferences

• Form 4: Facts About Asthma

• Form 5: Allergy Information

• Form 6: Smoking Cessation Information

• Form 7: Severity and Control Dials

• Form 8: Medication Options

• Form 9: Medication Planner

• Form 10: General Types of Asthma Medications

• Form 11: How to Use Your Inhaler Handouts

• Form 12: Asthma Diary

• Prior Authorization Forms

TABLE OF CONTENTS

ACE STUDY

ASTHMA HALF DAY CLINIC FLOW • Registration

� Check patient in at front desk and collect co-pay if applicable

• Nurse � Bring patient back to exam room � On “ambulatory intake form” enter chief complaint as “asthma shared decision making visit” � Update pharmacy information � Obtain vital signs and document them

� Weight � Height � Blood pressure � Heart rate � Respiratory rate � Temperature � Pulse ox (if short of breath or having difficulty breathing)

� Update tobacco use and exposed under “social habits” � Measure peak flow

� Chart best of 3 � Instruct patient how to test at home � Give patient peak flow meter

� Perform spirometry � Test 3 times, more if necessary � Print results for Health Coach and Provider to review

• Health Coach � Describe shared decision making approach � Complete Patient Information Sheet � Determine current understanding of asthma � Review what asthma is and how it is treated � Confirm comprehension of information � Identify treatment goals � Review spirometry results � Determine current asthma severity level � Work with patient to define medication preferences � Discuss regimen options � Negotiate a decision about treatment � Complete “Documentation Template” for Provider

• Provider � Perform physical examination � Teach back to confirm patient understands new treatment plan � Update asthma health maintenance in EMR � Write prescriptions � Review proper inhaler technique � Complete and give asthma action plan � Give asthma diary � Type up and give discharge instructions

• Check Out � Set up follow-up appointment in 1 month

SPIROMETRY

PROPER TECHNIQUE

� Enter patient information into device

� Have patient loosen tight clothing, remove dentures or gum, and relax

� Have patient stand up next to the exam table

� Explain that the purpose of the test is to see how much air a person’s lungs can hold and how quickly that air can

be expelled with forceful effort

� Demonstrate the maneuver for the patient

� First ask patient to blow all air out of their lungs (exhale completely)

� Then have patient take the deepest breath in, filling their lungs completely

� They should feel like their lungs are balloons filled so full they might pop

� Tell patient to place the mouthpiece just inside their mouth between their teeth and seal their lips tightly around

it to prevent air from leaking out

� Encourage patient to exhale as hard, fast, and long as they can

� Tell them to “blast” the air out

� For at least 6 seconds in adults and 3 seconds in children – the device will beep when it’s time to stop

� They should try to force as much air as possible out in the first second then keep exhaling until every last

air molecule has escaped

� Tell patient to “keep going” or “keep blowing” until their lungs are completely empty

� Have the patient rest for a few seconds until they feel ready to repeat the test

� Perform the test 3 times

� Test may need to be repeated for poor effort (often times machine will indicate this)

� Examples: if patient coughs, laughs, breaths in, or does not exhale for the full period of time

� Print the results

� Look at the flow-volume curve (top)

� The curve should be relatively smooth without significant “bumps” (these signify inhalations) – repeat if

needed

� Look at the flow-time curve (bottom)

� The curve should go to at least 6 seconds for adults and 3 seconds in children – repeat if needed

SPIROMETRY

PROGRAMMING INSTRUMENT

� Press and hold down the On/Off button for 2 seconds until you hear a beep and the screen lights up

� On the Main screen, Perform Test is automatically highlighted - click Enter to select

� On the Select Test screen, New is automatically highlighted - click Enter to select

� On the Enter Patient Data screen:

� For ID, enter patient’s MRN (ex: 12345678) - click Enter

� For Name, enter patient’s first and last name (use 0,ESC for the space, ex: John Smith) - click Enter

� For Age, enter the patient’s age in years (ex: 22) - click Enter

� For Height, enter number of feet then use the right arrow key (>) to move over to enter the number

of inches (ex: 5 > 5 for 5 feet and 5 inches) - click Enter

� For Weight, enter the number of pounds with 3 digits (ex: 075 or 180) - click Enter

� For Ethnicity, use the arrow keys to scroll between the options (Caucasian/Hispanic/Asian/

Other/African) until the correct one is highlighted - click Enter to select

� For Gender, use the arrow keys to scroll between the options (Male/Female) until the correct one is

highlighted - click Enter to select

� For Smoke, use the arrow keys to scroll between the options (No/Former/Yes) until the correct

one is highlighted - click Enter to select

� For Asthma, use the arrow keys to scroll between the options (No/Possible/Yes) until the correct

one is highlighted - click Enter to select

� On the Test screen, FVC (Expiratory) is automatically highlighted - click Enter to select

� On the Baseline Setting screen, insert the bottom of the spirette into the tube by lining up the arrows. Be

sure to push the spirette all the way in and keep the plastic wrapper around the mouthpiece to block it

until prompted to “blast out” - click Enter for Next

� If an Error Message appears, check the spirette insertion - click Enter for OK

� To go to a previous field, press and hold the 0,ESC button

� Left arrow (<) deletes the last character, scrolls to the left or up

� Right arrow (>) scrolls to the right or down

� Proceed to perform 3 tests (see proper technique)

� After obtaining 3 tests, pull out spirette and click Enter on Print, then place spirometer on dock to print report

ACE Study

Provider Documentation Template

SUBJECTIVE: Patient presents for an asthma shared decision making visit. Asthma treatment goals and preferences established through shared decision making by Health Coach, ___________. Patient information form reviewed. See scanned document for complete details. Patient’s perceived level of control: � Well controlled � Moderately well controlled � Poorly controlled � Very poorly controlled

Patient’s asthma treatment goals: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Patient’s ranked preferences regarding treatment options: _____ Control _____ Side effects _____ Cost _____ Convenience _____ Other

OBJECTIVE: Physical Examination Best Peak Flow: _____ Age-Predicted: _____ Green Zone (>80%): _____ Yellow Zone (60-80%): _____ to _____ Red Zone (<60%): _____ Spirometry results: FEV1: _____ FCV: _____ FEV1/FVC: _____

ASSESSMENT/PLAN: Patient’s severity level (for patient NOT on controller medicine): � Mild intermittent � Mild persistent � Moderate persistent � Severe persistent Patient’s actual level of control (for patients on controller medicine): � Well controlled � Not well controlled � Very poorly controlled Shared decision making medication selection: _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ Proper inhaler technique review. Patient demonstrated competence. Treatment plan teach-back provided. Asthma Action Plan updated and reviewed with patient. Asthma diary given. Patient to follow-up in 1 month to reassess.

ACE Study SDM Script

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Asthma Comparative

Effectiveness

ACE STUDY

ADULT SCRIPT

ASTHMA COMPARATIVE EFFECTIVENESS

(ACE) STUDY

Health Coach Protocol, Health Coach Resources,

and Patient Handouts

These materials may not be distributed, used, or adapted without written permission of the ACE Study Principal Investigators, Carolinas HealthCare System and the grantee institutions.


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Preparing for ACE STUDY Session

� Materials Needed:

o Patient medical chart REVIEWED PRIOR to session o Baseline spirometry results o Shared Decision Making binder for specific age

� Other Materials: o Asthma bronchial model and inhaler examples o “Taming the Wild Wheezes” book, opened to pages 2 and 3 o Electronic Medical Record (EMR), opened to patient’s chart

� Health Coach Resources and Patient Handouts: o Form #1: Patient Information Form o Form #2: How Well Controlled Is Your Asthma? (blank dial) o Form #3: Asthma Treatment Goals and Medications Preferences o Form #4: Facts About Asthma o Form #5: Allergies: Things You Can Do to Control Your Symptoms o Form #6: Smoking Cessation Resources o Form #7: How Severe or How Well Controlled Is Your Asthma? (dial with

symptoms and lung function) o Form #8: Medication Options to Control Asthma Chart (for specific age and

insurance type) o Form #9: Medication Planner o Form #10: General Types of Asthma Medications o Form #11: How to Use Your Inhaler o Form #12: One Week Asthma Diary o Asthma Controllers/Relievers Posters o Asthma Action Plan (EMR, website, or paper form)


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Set the Stage � Establish rapport � Describe shared decision making approach

Provide Information (Health Coach and/or Group Visit) � Determine current understanding of asthma � Review what asthma is and how it is treated � Confirm comprehension of information

Negotiation (Health Coach) � Summarize patient goals and information � Review spirometry results with patient � Provide assessment of patient’s current symptom control and

treatment level � Determine current asthma severity level � Work with patient to define medication preferences � Discuss regimen options � Negotiate a decision about treatment

Wrap Up (PCP) � Physical examination � Teach back � Update Asthma Health Maintenance in the EMR � Write/Fax prescription(s) � Review proper inhaler technique � Give Asthma Action Plan and diary � Set up follow up appointment

Gather Patient Information � Asthma symptoms and perceptions of control � Medication use � Alternative treatments used � Environmental triggers � Identify patient goals

Flow chart and process objectives for ACE STUDY


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SET THE STAGE: Health coach

� Establish Rapport � Describe shared decision making approach

� Hello, [Mr./Ms. [name]]. I’m [your name]. Thank you for coming today. I’ve been looking forward to our meeting.

Your asthma symptoms are significant enough for us to think there might be some things that can be done to improve them. I’d like for you to think of this as an opportunity to take a fresh look at how to take care of your asthma. In the past, your health care providers might have asked you questions about your asthma, examined you, and then said, “This is what your problem is, and this is the medicine you need to take. I’d like to see you again in a month to see how you are doing.”

We’ll approach your asthma care differently today. I would like for you to play a more active role than you might be used to. Your breathing test, symptoms, and medical history tell us something about your asthma. But I’d also like you to tell me how your asthma is affecting your life and what you hope to get out of the treatment. I will be asking you some questions about that today.

I’ll tell you the basic things we know about asthma and the different alternatives for treatment. Then we’ll work together to help you choose a plan that will work best for you. To put it simply, I would like for us to SHARE the decision-making about your asthma care as equal partners. This is not easy for some people, including some health professionals, but I would like for us to try. If you are wondering what it means to be an “equal partner” in your asthma care, don’t worry - your role will become clearer as we go along.

Once we’ve made a decision about the best approach for you, whether it’s the same as what you are doing now or very different, your primary care provider (PCP) will write it up as an Asthma Action Plan.

If you follow it as carefully as you can and record your symptoms and the medications you take in an Asthma Diary, we’ll be able to see how well the plan is meeting the goals you’ve set. And when we meet again in a month or so, we can make changes if you aren’t satisfied. How does that sound?

� Is there anything else you would like to get from this session?

If yes, restate and note the patient’s additional goals. If goals are highly unrealistic, indicate that you will talk more about this during the session and the possibilities for improvement.

� Do you have any questions for me now?


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Answer if question is straight-forward and/or indicate that this will be discussed in further detail in this or the next session.

Gather PATIENT information: Health coach

� Asthma symptoms anD perceptions of control � medication use � alternative treatments used � environmental triggers

� Let’s start with some general questions about your asthma.

� Complete Form #1: Patient Information Form. Ask ALL questions and any “probe” questions to clarify or give detail to patient answers.

You will use Form #2: How Well Controlled is your Asthma? during this process.

You will also need to provide Form #5: Allergies: Things You Can Do to Control Your Symptoms for patients with significant allergy responses and Form #6: Smoking Cessation Resources to patients who are smokers.

Note that a patient may give you information that is clearly based on a misunderstanding of asthma or asthma medications, or that indicates that he/she is engaging in behavior related to his/her asthma management that is incorrect or potentially harmful. If this occurs, it is acceptable to provide the necessary information or clarification at that time, including information that you would otherwise present during the “Provide Information” portion of the session. If you do this, be sure to quickly re-summarize that information again during the “Provide Information” portion of the script. � Identify Patient goals After completing Form #1: Patient Information Form, continue as follows:

� Given everything you have told me, what would you say are your primary goals for your asthma treatment - what do you want your asthma treatment to do for you?

� Complete the top of Form #3: Asthma Treatment Goals section. Try to elicit specific, personally meaningful goals (for example, types of activities patient would like to be able to do). If patient’s goal(s) is/are apparent from what they have already told you, state what you believe is/are their goal(s), and allow the patient to confirm this or make modifications/additions. For example, you might say the following:


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� From what you have been telling me, it seems that your primary goal for your asthma care would be to ______________. Would that be correct? Is there anything else that you want the treatment to do for you? If patient’s goal is extremely unrealistic (such as “I want to get rid of the symptoms, but I don’t want to take medicines everyday”), prompt patient to explore goals that are more feasible, using statements such as the following:

� Yes, everyone wants that, but it may be very difficult with existing treatments. Although we can’t eliminate your asthma entirely, we might be able to help you with some things that make it difficult to live with.

It may be very hard to control your asthma without daily medications, but we can talk about whether there might be changes in your environment or what kinds of medications you might take that would reduce the amount you need to take.

This is an opportunity to try to make some of those negative things about living with asthma better for you, so can you think of what you feel would be a noticeable improvement - one that would be meaningful to you?

If the patient’s goal appears unnecessarily limited (for example, the patient appears to have accepted very poor control, severe activity limitations, or does not realize that better control is possible), inquire whether they would be interested in reducing their symptoms or the risk of asthma flare-ups, or whether they’d like to be able to do some particular thing they have given up. For example, you might say:

� Many people, especially if they have had asthma for a long time, have gotten used to having symptoms or have given up on doing things they might like. However, with medications that are now available and better information on how to use them, most people can be free of symptoms most of the time and can lead an active life.

How would you feel about considering the possibility of reducing your symptoms and being able to be more active?

[If interested] We will talk about what medications might help you reach this goal and what you would need to do.


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Provide information: health coach

� Determine current understanding of asthma � Review what asthma is and how it is treated � Confirm comprehension of information

� Let’s talk for a few minutes about what asthma is.

How would you explain to someone who doesn’t have asthma what is happening in your lungs when you have an asthma episode?

How might you explain what is different about the lungs of someone who has asthma?

Listen to the patient’s explanations. Determine whether there is an understanding of asthma as a chronic problem and of the underlying mechanisms of bronchoconstriction and inflammation.

� Let’s look at these pictures and model of the lungs and see if it would help you explain asthma.

Show Form #4: Facts About Asthma and the airway model. Open the book “Taming the Wild Wheezes” to pages 2 and 3. Teach each bulleted topic in the handout and use the book to clarify. Concentrate on points the patient misunderstands, as evidenced by their initial explanation. Present all points listed. Patient misconceptions or unfounded concerns about side effects should be addressed, but without directly challenging the patient. As part of teaching about environmental triggers, provide patient with Form #5: Allergies: Things You Can Do to Control Your Symptoms.

Negotiation: health coach

� Summarize patient goals and information � Review spirometry results with patient

� Now let’s begin to consider treatment possibilities for you. Let’s start with what you told me about your goals for your asthma care.

Summarize patient goals as stated on Form #3: Asthma Treatment Goals.

� Is there anything important missing?

� Incorporate any additions or modifications that patient mentions.


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Begin the process of determining patient’s asthma severity. Start by reintroducing Form #2: How Well Controlled Is Your Asthma? on which the patient indicated his/her perceived level of asthma symptom control.

� Earlier you used this meter to show me how well-controlled you think your asthma symptoms are. You felt that it was [well/moderately well/poorly/or very poorly] controlled.

Let’s look at what your spirometry results and symptoms tell us about your control.

Present and review the patient’s spirometry results.

� FVC is the total volume of air you exhaled during the entire 6-10 seconds. FEV1 is the amount of air that you exhaled during the first second of that test. These values are shown as percentages of the average values for a [woman/man] of your age and height. How much air you can blow out in the first second, FEV1, tells us how much your airways are blocked by inflammation and bronchoconstriction. Your FEV1 is high (over 80%) if you can blow a lot of the air out in the first second. However, the more your airways are blocked, the longer it takes to blow the air out because you are trying to force the air through a smaller passage. That is what it means if your FEV1 is low.

Discuss what the results mean in terms of amount of obstruction and potential for improvement. � Provide assessment of patient’s current symptoms � control and treatment level � Determine current asthma severity level

Turn to Form #7: How Severe is Your Asthma? (for patients NOT on a controller medication) or Form #7: How Well Controlled Is Your Asthma? (for patients on a controller medication).

� This handout has some guidelines that can be used to give a more specific indication of whether someone’s asthma is [mild/moderate/severe (for patients not on a controller medication)] or is well-controlled or not (for patients on a controller medication), based on symptoms and lung function. For example, well-controlled asthma (the green area) means that a person has:

� Symptoms < 2 days a week � Nighttime awakenings ≤ 2 times a month � No interference with normal activity � Albuterol use (rescue medicine) ≤ 2 days a week � Normal FEV1 between exacerbations � FEV1 > 80% predicted, FEV1/FVC normal � Exacerbations requiring oral steroids 0-1 times a year

Using these symptoms and lung function guidelines, in what category would you place yourself on


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this severity/control meter?

NOTE: If there is a discrepancy in the level of severity/control implied by symptoms versus lung function, you should use whichever criterion suggests a poorer level of control. You may apply clinical judgment if you suspect patient is a “poor perceiver” or is minimizing/denying perceived symptoms. Compare this level of severity/control with patient’s earlier estimate. If different, ask patient to explain why they think their earlier estimate was different from the current estimate. For patients NOT on a controller medication – use the severity classification on the dial [mild intermittent or mild/moderate/severe persistent] to determine which “Step” to consider initiating treatment. For patient on a controller medication – identify the control level [well controlled, not well controlled, or very poorly controlled] to decide whether to maintain, step down or step up therapy.

� Now let’s look at the various options that are used to treat asthma of this severity/control level and talk about ones that might enable you to meet your goals.

� Work with patient to define medication preferences Show patient Form #8: Medication Options to Control Asthma. *Be sure to select the formulary that matches the patient’s age and insurance type*

� Here is a list of asthma controller medications and the dosages usually used to treat mild, moderate, or severe asthma.

You can see that as the severity of the asthma increases (going from the yellow to the orange and red areas), more puffs are usually prescribed and the frequency of the inhaled medications may change to twice a day rather than once. [Point to an example]

Often, for more severe asthma, different medications are added that have different effects on inflammation and dilation of the airways. [Point to an example]

This is the full range of medications that are currently available to control asthma. Some of the medications and combinations give more control over inflammation than do others. However, some combinations have other advantages.

Return to Form #3: and refer to the bottom section listing Medication Preferences (typically cost, control, side effects, and convenience). If the preferences of most and least concern to the patient are obvious from the previous discussion, start by ranking them.


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� We’ve listed your treatment goals. We know you want [goal] and [goal] and that you want/are concerned about [preference]. That suggests that you might be interested in medications that provide [some/moderate/very good/excellent] control over symptoms and inflammation and that you might be less happy with a medication that provided [more/less] control. (If control of symptoms/inflammation is part of patient’s goal, check “Control” box under “Preferences”)

Is paying for your medications a concern for you? [Or] You have mentioned that the cost of medications is a concern for you. I can suggest some generic options that will be more affordable. (If cost is a concern, check “Cost” box under “Preferences”)

We can talk about potential side effects, where there are any, as we consider specific medications. [If relevant] I know you are concerned about [summarize any previously stated concerns]. (If patient has specific concern, check “Side Effects” box under “Preferences”)

Convenience is really an individual matter. You can see that the medications on this list differ in how much they require you to do. Most are inhaled, but they come in different types of inhalers, and one is in a tablet form. [If relevant] You have said that it is important to you that [insert specific considerations regarding schedule, dosing, form of medication, type of inhaler, etc.] We will keep that in mind when we talk about specific medications and whether they will meet your needs.

� Discuss regimen options � Negotiate a decision about treatment

� With those things in mind, let’s talk about which treatment options might meet your goals and preferences.

Your current medication(s) and the way you are taking it/them might end up being what you feel best meets your needs, but if we go over some other options, then at least you will know what else is available to choose from. Would that be OK with you?

Discuss specific options for patient’s regimen, based on ASTHMA SEVERITY, TREATMENT GOALS, and MEDICATION PREFERENCES that are important to the patient. Do not rule out any options. You and the patient should consider regimens that are listed for the patient’s severity level, but in some instances the patient may not accept any of these options as listed and you may have to negotiate options listed for a lower severity level than the patient’s. In these cases, the patient should be informed that such a regimen is unlikely to control their asthma adequately. � Some issues to consider in negotiation are:

o Relevant co-morbidities and concomitant medications that may influence the choice of asthma prescriptions. Ask for any necessary clarifications or additional in formation from patient.


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� Chronic Rhinosinusitis: o If patient scored 2 or more on chronic rhinosinusitis items asked on Form #1: Patient

Information Form, incorporate negotiation of a prescription for a nasal steroid spray (Flonase, Nasonex) or antihistamine (Claritin, Zyrtec, Allegra) to take during the period between today’s session and the follow-up appointment. Recheck at the follow-up appointment to determine whether continued use is appropriate.

� GERD o If patient said yes to any of the 3 GERD items asked on Form #1: Patient Information

Form, incorporate negotiation of a proton pump inhibitor (PPI – Prilosec, Prevacid, Nexium, Protonix or H2 Blocker – Zantac, Pepcid).

� If patient has had problems using specific asthma medications:

o Avoid choosing a medication that has caused the patient problems (e.g., past intolerance of Asmanex) unless you have reason to suspect that reported problems with medication were not actually due to the medication or could be mitigated by specific measures to avoid side effects (e.g., spacer, rinsing mouth, reminder aids).

o If poor inhaler technique is an issue in terms of medication efficacy or side effects, assure patient that they will be taught how to use the device correctly or use a device/spacer and rinse mouth to minimize problems due to technique.

� Special consideration for discussing Singulair alone as routine controller: o Discussion of this regimen’s features (pros and cons) should include telling patients that those

who regularly take ONLY Singulair typically need to add an ICS when they have a URI. o Patients who are just beginning a regimen of Singulair as their only controller

should be instructed that if a URI is accompanied by asthma symptoms, then adding an ICS will be needed. Those patients should be instructed to call you if they have a URI, as soon as they begin to experience a worsening of asthma symptoms. You may need to add an ICS to their regimen at that time, but a standing prescription will not automatically be provided.

� For patients who have used or are currently using Singulair as their only controller, you should investigate their previous history regarding URIs and their effects on the patient’s asthma to determine whether they will need to add an ICS when they experience a URI.

o Negotiation should consider including an ICS on the Asthma Action Plan as part of treatment during URI for patients for whom you believe it might be necessary.

� Stepping up versus stepping down regimens: o This is a potentially useful point of negotiation with patients. Patients whose primary goal is to

get control of their asthma may choose to begin treatment with a strong dose of medication and attempt to reduce the dose when their symptoms have been controlled. Patients who are hesitant or concerned about strong doses of medication may prefer to start with a lower dose and gradually step up to a level that adequately controls their symptoms.

Select a medication regimen from the listed options to begin discussion with patient, considering patient’s expressed GOALS and PREFERENCES.


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Discuss the current regimen option with patient using Form #9: Medication Planner.

� Form #9: Medication Planner:

1. Fill in current regimen and list important goals and preferences, writing in how the regimen measures up on patient’s goals and preferences.

2. If current de facto regimen does not include regular use of any controller, the inadequate control provided by this option must be mentioned (with the associated risks for a severe exacerbation) along with benefits the patient may see (e.g. low cost, convenience).

3. Patients may be using, or want to consider using, a controller only during their “bad” seasons. The pros and cons of this option, which is not one of the standard recommendations, should be discussed. That the patient has been informed of these considerations must be documented on the patient’s Asthma Action Plan if a non-recommended option is negotiated. Similarly, if the patient refuses to use any controller on a regular basis, that needs to be documented on the Asthma Action Plan.

� Write first new option on Form #9: Medication Planner.

1. Describe how the option meets their specific goals and preferences.

2. Highlight degree of control it affords (or limitations in this regard compared with other

options).

3. Mention other relevant features of the medication. With regard to cost, estimate cost to patient

of a 1-month supply based on their insurance status. Cost to the patient will primarily be

determined by their co-pay amount and the total number of different medications they are

taking (including non-asthma medications). However, if patient has a medication cap, then

consider whether the regimen will cause them to reach the cap before the year is over, taking

into account other regular medication use as well.

4. Incorporate reduction of environmental triggers as appropriate. If there is trigger/allergen

exposure, discuss whether or not patient could/would change exposure, and how this might

influence medication requirement.

5. Incorporate negotiation of spacer use if patient currently does not use or uses one inconsistently.

Present a spacer as one way to avoid side effects (thrush) while simultaneously providing more

symptom control.

� Present a second option from the prescribing guidelines. If patient has goals or preferences that are not satisfied by the first option, then the second option presented should focus on the next


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most important preference that the patient identified. If the first option addressed the patient’s preferences but was not the option that provides optimal control, then it might be useful for the second option presented to be one step up from the first one in terms of control

1. Write it down on Form #9: Medication Planner as Option #2

2. Start by contrasting this option with the first new option and the current regimen. How does it

differ?

3. Discuss level of control offered.

4. Discuss less important features last or omit if not relevant. Include estimated cost information.

5. Incorporate reduction of environmental triggers and/or spacer use as above.

� Present a third option? o If patient hesitates or does not seem satisfied with either of the first two, move on to the next

best-fitting option for their situation using prescribing guidelines.

o When all options have been laid out, revisit environmental control issues. If patient will not

make certain changes that could improve asthma control (e.g, cease smoking, give up a pet),

urge patient toward an option that offers greater control.

o If patient is willing to make environmental changes that could reduce symptoms, then they

would be more justified in choosing a regimen that might offer less control but that is better in

terms of convenience, cost, and/or potential for side effects.

� Let’s take one last look at Form #3: Asthma Goals and Medications Preferences worksheet where we recorded your preferences. How well do you think this plan addresses your goals and preferences?

� We’ve decided that you want to try/continue taking ______________. We have gone over all of

the pluses and minuses of this plan. Do you feel you are satisfied and ready to give this a try? Do you have any questions about it?

***At this point, the patient’s care will be transferred from the Health Coach to the Primary Care Provider. The Health Coach will need to complete all paperwork and give the forms to the PCP for review and documentation.***


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WRAP UP: PCP

� Physical examination � Teach back � Update Asthma health maintenance in the EMR � Write prescriptions � teach proper inhaler technique

� Hello __________. Looking at your medication planner, could you go over what you and the health coach decided about your asthma treatment plan?

I am going to write you a prescription for _____________ (and __) that you can have filled today [or within 3 days if non-formulary medication is prescribed]. Here are some information sheets on these medications that you can take home with you. They may help if you have questions.

Give patient a copy of the relevant handouts from Form #10: General Types of Asthma Medications (i.e., those that correspond to their prescriptions). For all patients include:

1. The handout for short-acting beta agonists 2. The handout describing the difference between controllers and relievers, and 3. The handout “How Long Will Your Canister Last?”

� Give Asthma action plan

Provide an Asthma Action Plan to all patients, even if the patient is going to continue on the same regimen and already has an action plan. This can be completed in paper format, through the electronic medical record, or online depending on clinic’s preference.

� I’ll also write this down on your personal Asthma Action Plan.

� 1. Write down the agreed-upon regimen in the “Green Zone.” 2. You may use your clinical judgment in deciding whether to instruct a patient to contact you if

(s)he experiences symptoms in the “Yellow Zone” of the action plan. 3. Consider prescribing (and include on action plan for “Red Zone” symptoms) a prescription for

an oral corticosteroid “burst.” i. For example - Prednisone (20 mg tablets) -take 40 mg (two 20 mg pills) for 5-10

days until symptoms are back to baseline for 48 hours. ii. If patient uses a peak flow meter, then it can be incorporated into the description

of the action plan, but do not actively encourage or discourage peak flow meter use. You may use a peak flow meter during the session to help you later evaluate


15

the efficacy of therapy if you choose. 4. When discussing “Red Zone” symptoms, instruct patients that if there is an escalation and

persistence of symptoms listed (not just presence of those symptoms), they should call their PCP or triage nurse, who will advise them on what actions to take. Patients should go to the ER/urgent care or call 911 if they experience symptoms that include: (1) having trouble walking or talking due to shortness of breath, or (2) having lips or fingers turn blue or grey.

5. Check patient’s understanding of routine medication schedule and action plan.

� I’d like for you to pretend that I am a family member who wants to know what your asthma medication schedule is and what you would do if you have symptoms. Can you practice telling me what you would say? Include all the information - the medication name(s), the amount, and the frequency. Make sure patient can describe his/her action plan accurately. Coach until (s)he can state it correctly. � Review proper inhaler technique

� It is also important to make sure that your inhaled medicine(s) really get(s) down into your lungs

where it/they will be the most effective in reducing your asthma symptoms.

If inhalers are not used correctly, the medications don’t help much because they can’t get all the way down into the narrow airways where the asthmatic reaction is taking place. That is true for both your albuterol (quick relief medicine) and the inhaled controller medications.

If patient uses both an HFA and a DPI ( Advair Diskus)

� It can also be difficult for patients using both types of inhalers - HFA’s and DPl’s -because the proper techniques for the two are different in ways that can be confusing.

Let’s take a minute before we finish here to review the correct way to use your inhaler(s).

Review and demonstrate proper inhaler technique for patient using all relevant sheets from Form #11: How to Use Your Inhaler.

Then have patient demonstrate technique. Coach until proper technique is achieved, using checklist on the last page of Form #11: How to Use Your Inhaler. If more than one type of inhaler is prescribed, highlight differences between the two as you review, demonstrate and coach. (Note: all patients should get demo of HFA for use of their albuterol inhaler) Give patient a copy of only the relevant handouts from Form #11: How to Use Your Inhaler (i.e.,


16

� You might not see as much of a change in your symptoms as you would with a more intense plan, but this will help you to see how much improvement you get.

� You probably won’t see very much change right away, but if you are taking the medicine every day, you should begin noticing that your symptoms are getting a bit better within a couple of weeks.

If they have chosen a regimen with good control.

If they have chosen a regimen with less control.

those that correspond to their prescriptions). All patients should receive an HFA inhaler use handout. If appropriate to the patient’s inhaler, prescribe a spacer and emphasize its effectiveness in delivering medication. The strength of the recommendation to use a spacer should be directly proportional to the strength of the medication(s) patient is taking because the potential for side effects (e.g. thrush) increases as the medication strength increases. Provide all patients with information about proper cleaning of spacer. If patient has brought his/her spacer, check its condition to determine whether a new one should be prescribed. � Give asthma Diary � Set up follow up appointment

� OK, this is our plan! You have a prescription(s) and we have reviewed your inhaler technique together, and you’ve agreed to try this medication for one month. Then we will meet again and talk about how things are going for you.

It is very important for you to really give this plan a chance to work. I’d like for you to keep track of your asthma symptoms from now until our next meeting. It can be very helpful to closely follow what is happening with your symptoms. Have you ever kept an Asthma Diary? Sometimes when we keep track of things carefully, we begin to see patterns that we didn’t notice before.

Show patient Form #12: One Week Asthma Diary and explain how to fill it out. Have patient complete Day l column for the day preceding this session. Determine whether patient understands how to complete the diary. Answer any questions. Give patient 4 copies.

� We can talk about what has happened and how you feel about it when you come back in a month

for your follow-up appointment. If something doesn’t seem right or you have a question, please


17

feel free to call me in between. I’d rather you called me than to wait and find out something hadn’t gone right. Does this sound OK? How confident do you feel about being able to take this/these medications for the next month?

Affirm their choice if they don’t seem especially confident. Explore barriers and try to identify ways to overcome them. Assure them that they can change the plan if it is not working for them.

� When you check out, a follow-up appointment can be scheduled in approximately 1 month from now.

� Indicate on discharge paperwork that follow-up appointment is to be scheduled in approximately 1 month.

� We will make copies of the forms we completed today, so that you and I can both have them. Make photocopies of the following forms: (scan into EMR)

o Asthma goals/preferences o Medication planner o Asthma action plan (if completing paper or online version)

� Here are your copies of the forms and discharge papers. If you do have problems with

your asthma (if you get into the red zone on your action plan), you should follow the instructions on the Asthma Action Plan “Red Zone” regarding your medication use and contact me or the triage nurse. Of course, if the problem is severe, as the action plan indicates, you should seek urgent care or ER care, or call 911. Contact me afterward if you have had to go to urgent care or the ER for asthma. Is there anything else you would like to ask or discuss?

I would like to thank you for coming in today. I look forward to seeing you next time.

ACE Study SDM Follow-Up Script 1

Asthma Comparative

Effectiveness

ACE STUDY

ADULT FOLLOW-UP SCRIPT

ASTHMA COMPARATIVE EFFECTIVENESS

(ACE) STUDY

These materials may not be distributed, used, or adapted without written permission of the ACE Study Principal Investigators, Carolinas HealthCare System and the grantee institutions.


Preparing for SDM Follow-Up Visit

Overview: • Introduction • Review Session 1, phone calls • Evaluation of regimen • Discussion/Negotiation of additional treatment options (as necessary) • Wrap Up

Materials Needed:

• Patient medical chart (REVIEW BEFORE SESSION) • Baseline spirometry results • Follow-Up Script • Patient’s chart with Session 1 forms:

o Form # 1: Patient Information Form (review before session) o Form # 3: Asthma Treatment Goals/Medication Preferences worksheet o Form # 9: Medication planner worksheet o Asthma action plan

• Patient Information Form — Follow Up • Asthma Controllers/Relievers poster • Form # 8: Medication Options to Control Asthma Chart • Form # 11: Checklist for Proper Inhaler Use/How to Use Your Inhaler • Form # 12: One Week Asthma Diary (4 copies)

Follow-Up Session Scheduling Note: Follow-up sessions should occur approximately one month after Session 1. Occasionally a patient may be unable to schedule a visit at one-month due to travel or other reasons, or may fail to keep his/her follow-up appointment and you will have to reschedule the follow-up visit. You should make every attempt to complete the follow-up visits within six weeks of Session 1. However, in some cases, there may be patients for whom you have great difficulty doing so, despite several attempts.


Flow chart and process objectives for SDM Intervention Follow-Up Session

Introduction • Reminder of shared decision making approach • Summary of what will be covered in Follow-Up Session

Evaluation of regimen and current inhaler use • Evaluation of regimen and current inhaler use • Review Session 1 goals and treatment decision • Review content of any phone communication since Session 1 • Assess patient adherence to regimen, including any reasons for nonadherence • Review of asthma diaries (i.e., recent asthma symptoms) • Elicit patient’s perceptions of regimen success • Re-assess inhaler technique

Discussion/negotiation of additional treatment options (as necessary) • Determine whether to initiate discussion of new treatment options • If no discussion is needed, skip to wrap up • If new discussion is needed: • Present new options

o Engage in negotiation o Make a decision about treatment regimen o If warranted, write new prescription, complete action plan. Give new medication handouts and

inhaler use handouts

Wrap Up • Give all patients a new set of asthma diaries • Encourage patients to call with questions when needed • Schedule follow-up appointment in 1-6 months (depending on severity and level of control)


SDM Follow-Up Session Introduction Remind patient that sessions will be conducted using a shared decision making approach in which the patient, health coach, and PCP work together to find the best way to achieve patient’s asthma treatment goals.

• Summarize what will be covered in the session

• Brief review of things discussed in Session 1 and in interim phone calls (if any)

• Evaluation of current regimen, using symptom diaries completed during last 4 weeks and asthma goals listed at Session 1

• Discussion and negotiation of additional treatment options, if necessary

• Discussion of plans for follow-up (in 1-6 months depending on severity and level of control)

Evaluation of regimen and current inhaler use • Briefly review with patient his/her stated treatment goals and medication preferences using Session l’s Form # 3:

Asthma Treatment Goals and Medication Preferences worksheet. • Briefly review with patient the treatment decision that was made using Session 1’s Form # 9: Medication Planner and

the Asthma Action Plan. • Mention the content of any phone contacts that took place between Sessions 1 and 2, noting any changes made in regimen

or concerns addressed. • [Using Patient Information Form] Review with patient his/her asthma symptoms since Session 1 (approximately one

month ago). Use the patient’s completed Asthma Symptom Diary (4 -1-week copies) to facilitate this conversation. Check the following:

o How often has patient been experiencing asthma symptoms during the daytime? o How often has patient been awakened at night by asthma symptoms? o How often has patient used a short-acting beta agonist inhaler (albuterol) for quick relief from asthma

symptoms? o Has patient gotten any medical care for asthma since the last time you spoke? If so, what was the reason? If

yes, was any treatment administered or any changes made in the patient’s asthma regimen? • Ask patient how well the regimen is meeting his/her stated goals and preferences, including both goals related and

unrelated to symptom control that were not discussed above. Acknowledge the patient’s experience - successes or problems.

• Assess patient’s adherence to current regimen. Find out specifically what patient has been taking (using Asthma

Controllers/Relievers Poster if necessary), on what schedule, and with what regularity. If patient has not been adherent, probe for reasons.

• If patient has had adherence problems, try to determine whether nonadherence is a CAUSE or CONSEQUENCE of any

expressed dissatisfaction with treatment outcomes. • If nonadherence seems to be a cause, explore barriers and try to find solutions. • If nonadherence seems to be a consequence of the treatment not having met the patient’s goals (i.e., the patient really

gave the regimen a chance to work), then consider whether patient wishes to consider some change in treatment.


• Re-assess patient’s current inhaler technique, using Form # 11: Checklist for Proper Inhaler Use/How to Use Your Inhaler. Have patient demonstrate for all relevant inhalers. Coach and correct any errors. Provide patient with new copy/copies of Inhaler Use handouts if patient continues to need practice with technique, or no longer has original copies.

Discussion/negotiation of additional treatment options (as necessary)

• Determine whether to initiate discussion of new treatment options. Assess using the following questions:

1. Are patient goals and preferences being adequately met? 2. Have symptoms deteriorated or not improved such that discussion of a stronger regimen is warranted? 3. Do side effects need to be addressed? 4. Is there a reason to consider stepping down therapy? 5. Is there new information that might change the assessment of the patient’s level of control, using Form #7: How

Well Controlled Is Your Asthma? 6. Has patient modified his/her goals since Session 1? If so, complete a new, blank copy of Form # 3: Asthma

Treatment Goals and Medication Preferences worksheet.

• If no discussion negotiation is needed, skip to Wrap Up with the Primary Care Provider: • If new discussion/negotiation is needed:

1. Consult Session 1’s Form # 9: Medication Planner worksheet. 2. As appropriate for addressing patient’s current concerns, revisit one or more of the treatment options that were not

chosen but are listed on the Medication Planner. 3. Use a new, blank copy of Form # 9: Medication Planner worksheet to write down any options considered at

Session 1 that are being reconsidered now. Once again, discuss options in terms of patient’s current goals and preferences. Compare and contrast with current regimen.

4. Add to the worksheet any new treatment options not discussed at Session 1 that may now be relevant for patient goals or preferences. Discuss option in terms of goals and preferences. Compare and contrast with other listed options and current regimen.

5. Engage patient in discussion of their preference for new regimen. 6. Establish specific agreement for medication use and how its success will be evaluated.

* At this point the patient’s care will be transferred from the Health Coach to the Primary Care Provider * • If patient has decided to try a new regimen:

1. Write a prescription for new regimen 2. Complete and review new Asthma Action Plan. 3. Provide teach back to make sure patient can describe his/her plan accurately. 4. Provide patient with new Form #10: General Types of Asthma Medications, if different medications will be

used. 5. Provide patient with new Form #11: How to Use Your Inhaler if different types of inhalers will be used.

Wrap Up Give all patients 4 new copies of Form #12: Asthma Diary sheets. For those continuing on their Session 1 regimen, urge them to continue tracking their symptoms for one more month. For those with a new regimen, explain that the diaries will help them determine how well the new regimen is working. Schedule follow-up appointment for patient in 1-6 months depending on their severity or level of control. Patients now under good control may not need to be seen for 3-6 months. Those with severe persistent asthma under poor control will likely need to be seen again in 1 month.


• Make photocopies of the following forms:

• Patient’s completed diaries from Session 1 • New Form # 3: Asthma Treatment Goals and Medication Preferences (if applicable) • New Form #9: Medication Planner (if applicable) • New Asthma Action Plan (if applicable)

o Give patient the originals of these forms. After patient leaves:

1. Add any copies of diaries, asthma goals worksheet, medication planner, and new action plan to patient’s chart. 2. Document all relevant information from the session in patient’s medical record.

Question Probe Notes

• How much does asthma get in the way in terms of your daily living - for example, does it affect your daily life?

� Activity level � Work and/or home life � Relationships with friends/family � Finances � How you see yourself � Anything else?

• Of these things you just mentioned, what bothers you the most or what would you most like to change?

• How long have you had asthma?

• Years ____________


• In the past 4 weeks, did your asthma wake you up at night (including asthma-related coughing)?

• [If yes] How often? • Awakened at night? � Y � N • Frequency or # of times? ___________

• In the past 4 weeks, did you miss any normal daily activity because of your asth-ma?

• [If yes] How often? • Missed daily activity? � Y � N • Frequency or # of times? ___________

• How often do you experience episodes in which your asthma is especially bad (we call these asthma exacerbations, attacks, or flares)?

• Have you ever had to go to the ER or an urgent care during an asthma attack?

• [If yes] When was the last time?

• Have you been hospitalized because of your asthma?

• [If yes] When was the last time? • Have you ever been intubated (had a breathing tube inserted)?

• Do you experience a cough with your asth-ma?

• [If yes] How often? • What is the cough like?

• How well-controlled do you think your asthma symptoms are?

F O R M # 1: P AT I E N T I N F O R MAT I O N F O R M

Symptoms

Asthma Bother

ACE Study Form #1: Pt Info Form, Page 1 of 4

EMR Sticker

G O TO FORM #2: HOW WELL

CONTROLLED IS YOUR ASTHMA

A N D H AV E PATI E N T I N D I C AT E W H E R E

T H E Y T H I N K TH E I R C O N T ROL I S B Y

MOV I N G T H E A R ROW .

Form completed by: _____________________ Date: _____________


Y � N �

Y � N �

Y � N �

Y � N �

Y � N �

Y � N �

# Y ______

What are your CURRENT PRESCRIPTIONS for asthma?

Let’s start with albuterol.

For each medication:

� How many puffs/pills are you supposed to take

each time?

� How often is it supposed to be taken?

� How many days did you take it last week?

� How many puffs/pills do you usually take?

� How do you think this medication works for your

asthma?

� Med 1 _ALBUTEROL_ Rx: _______________

# days taken last week _________ Usual # of puffs ________

How patient thinks it works: ____________________

� Med 2 ______________ Rx: _______________

# days taken last week _________

Usual # of puffs ________


� Med 3 ______________ Rx: _______________


Usual # of puffs ________


� Med 4 ______________ Rx: _______________


Usual # of puffs ________ How patient thinks it works: ____________________

Show me how you use your inhaler? [Examine technique using appropriate “Skills Checklist” on the last page. Note errors, but do no correct. Provider will review in detail and give patient handouts.]

Y � N �

Y � N �

Y � N �

# Y ______

Chronic rhinosinusitis:

• Do you usually have a stuffy, runny, or plugged nose for much of the year?

• Do you often have itchy, watery eyes?

• Do you have drainage in the back of your throat (post-nasal drip) most of the year?

• Has your health care provider told you that you have chronic sinus problems or allergies?

• When you have a head cold, do your nasal symptoms usually last for 3 months or more? • Are you unable to smell scents?

Gerd:

• Do you have heartburn or indigestion?

• Does food sometimes come up in the back of your throat (regurgitation)?

• In the past 4 weeks, have you had coughing, wheezing, or shortness of breath that was not relieved by taking albuterol?

Medication Use: show Asthma Controllers/Relievers posters

EMR Sticker


EMR Sticker


• Many people have a hard time taking their controller medication on the prescribed schedule.

• How often do you miss taking a dose of your controller medication(s)? [State name(s)]

• What is the reason? [Examples: forgetting, being too tired or busy, deciding not to]

• Almost everyone tries cutting back on their controller medications at some point, or they don’t take them as often or in the amount their doctor prescribes.

• What situations have led you to decrease your controller medications in the past?

• What happened? • Did you continue taking a decreased amount or stop altogether?

• How did that work out?

• Have you tried taking more of your controller medications than what was prescribed by your doctor?

• What led you to do this? • What happened when you did it?

• What asthma medications have you tried in the past that you feel did not help or that caused you problems?

• What happened when you took them? [Probe if reported problems are unlikely to be attributed to the medication]

• What did you do about that? • Did any other asthma medications give you problems?

• How do/would you feel about taking asthma controller medications on a regular basis?

• Are there any other things that might bother you about taking asthma medications every day?

• What are the worst things about tak-

ing asthma

medications every day? • Do you believe that taking controller

medications more regularly would

make any difference in your asthma?

• [If no] Why not?

• Are you concerned about side effects of any asthma medications?

• What are you concerned about? [Probe further if side effects men-tioned have not been documented]

• •


• Have you ever tried anything other than prescription medications to help with your asthma? For example:

� Vitamins � Herbs � Acupuncture � Deep breathing yoga � Seeing a chiropractor � Anything else?

• [For each] Did it help your asthma?

• Do you think any of these things were helpful in reducing your asthma symptoms?

• [If no] Do you have any thoughts on why this didn't work for you?

• Did you add this/these treatments to your prescription medications or did you try to use them as an alternative to taking medication?


• Are there different times of the year that your asthma is better or worse?

• When is it worse? Worse at times? � Y � N When? ______________

• Are there certain things in your surroundings that you know affect your asthma?

• [If yes] Can you give an example?

• What changes have you made in your surroundings in order to avoid your asthma symptoms?

• Has that been helpful?

• Are there changes that you think you should make that you haven’t decided to or haven’t been able to do yet?

• What are they?

• What gets in the way of these

• Are you a smoker? • [If yes] Have you tried to quit? • I will give you some information on programs to help people quit and I want to encourage you to take advantage of them. This is particu-larly important because you have asthma.

� Check box indicating that you have recommended cessation and provided handout resources for smokers.


Alternative Treatments

environmental triggers

EMR Sticker

If necessary for this section, show pictures on the Asthma Controllers/Relievers poster.

Patient Information Form— follow up Session

ACE Study Form #1: P.I. Follow Up Form Page 1 of 1

� How often have you experienced asthma symptoms during the

daytime?

� How often have you been awakened at night by asthma symp-toms?

� How often have you used a beta agonist inhaler (albuterol) for

quick relief from asthma symptoms? (NOTE: If patient has

brought back asthma diaries, refer to diary information when

discussing this with a patient.) � Have you gotten any medical care for asthma since the last

time we spoke/met? [If yes] What as the reason?

� Was there any treatment administered or were any changes

made in your asthma regimen? � How do you feel about your current symptoms, or changes or

changes in your symptoms, since Session 1? IS this treatment

plan meeting your goals and preferences? (Acknowledge pa-

tient’s experience—successes or problems)

Question/Diary Review Notes on patient responses/ Diary Data

What controller medications have you been taking since we last met/spoke? (NOTE: Again, if patient has brought asthma diaries, refer to diary information when discussing this with the patient.) For each medication: � What is the dosage you have been taking and on what schedule? � How many days in this week did you take ________ on this

schedule? [If patient has not been adherent] What has kept you from taking

your ________ as prescribed?

(If non-adherence seems to be causing dissatisfaction with out-

comes, explore barriers to adherence and try to find solutions.) If patient has had adherence problems, try to determine whether

non-adherence is a CAUSE or CONSEQUENCE of any expressed

dissatisfaction with treatment outcomes. (If non-adherence seems to be a consequence of unsatisfactory

treatment results (i.e., the patient really gave the regimen a chance

to work), then consider whether a change in regimen is indicated.

� Med 1 ALBUTEROL Rx: __________________


Usual # of puffs ________ How patient thinks it works: _____________________

� Med 2 ______________ Rx: _______________


Usual # of puffs ________ How patient thinks it works: _____________________

� Med 3 ______________ Rx: _______________


How patient thinks it works: _____________________

� Med 4 ______________ Rx: _______________


How patient thinks it works: _____________________

EMR Sticker

ASTHMA RELIEVERS

Generic Albuterol

ProAir HFA

Ventolin HFA

Proventil HFA

Xopenex HFA

Xopenex Nebulizer Solution

Albuterol Nebulizer Solution

Singulair

Symbicort

ASTHMA CONTROLLERS

Advair Diskus

Asmanex Twisthaler

Advair HFA

Flovent HFA

Pulmicort Respules

Qvar

Qvar

Pulmicort Flexhaler

Form #2: How well controlled is your asthma?

ACE Study Form #2: Control Dial Page 1 of 1

Form #3: Asthma Treatment Goals

• Activities: _______________________________________________________ _______________________________________________________________

_______________________________________________________________

• Other Concerns: _________________________________________________ _______________________________________________________________

_______________________________________________________________

MEDICATION PREFERENCES

� Control Over Inflammation and Symptoms ________________________________________________________________

________________________________________________________________

� Side Effects

________________________________________________________________

________________________________________________________________

� Cost

________________________________________________________________

________________________________________________________________

� Convenience

________________________________________________________________

________________________________________________________________

� Other

________________________________________________________________

________________________________________________________________

ACE Study Form #3:Goals Page 1 of 1

Form #4: Facts About Asthma

In Control NOT in Control

Asthma is a disease of the airways in your lungs. When someone with asthma breathes in one

of their “triggers,” it causes their airways to get smaller. Doctors call this “bronchospasm.”

This makes it harder to breathe and can lead to an asthma attack.

Swelling/Inflammation

Extra Mucus

Tightening Muscles

Tightening

Muscles

Swelling

Extra

Mucus

3 main things cause the airways to get smaller:

There are 2 types of Asthma Medications

Controller Rescue

• These medicines are only taken when you have

symptoms to relieve asthma symptoms right away.

• Rescue medicines relieve the tightening of muscles

around your air tubes.

• Tell your doctor if you use these more than 2 times a

week. You may need a stronger controller medication.

• These medicines are taken every day to prevent and

control asthma symptoms.

• They do NOT relieve symptoms once they start.

• Controllers work slowly over time to decrease

swelling and extra mucus in your air tubes.

Examples:

Examples:


Extra Mucus

Tightening Muscles


Extra Mucus

Tightening Muscles

Generic Albuterol Ventolin HFA

Albuterol Nebulizer

Solution Proventil HFA

ProAir HFA Xopenex Nebulizer

Solution

Xopenex HFA

Symbicort Asmanex

Twisthaler

Singulair Advair Diskus Advair HFA

Qvar Pulmicort Respules Flovent HFA Pulmicort Flexhaler

ACE Study Form #5: Allergy Info, Page 1 of 3

Form #5: Allergies: Things You Can Do to Control Your Symptoms

What causes allergies?

You have an allergy when your body overreacts to things that don't cause problems for most people. These things are called allergens. Your body's overreaction to the allergens is what causes symptoms (see the box below for a list of symptoms). For example, sometimes the term "hay fever" is used to describe your body's allergic reaction to seasonal allergens in the air, such as grass or pollen. Keeping a record of your allergy symptoms over a period of time can help you and your doctor identify which allergens cause you to overreact. Your doctor may want to do an allergy skin test to help determine exactly what is causing your allergy. An allergy skin test puts tiny amounts of allergens onto your skin to see which ones you react to. Once you know which allergens you are allergic to, you and your doctor can decide the best treatment. Your doctor may also decide to do a blood test, such as the radioallergosorbent test (called RAST).

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Common Allergy Symptoms:

• Runny nose • Watery eyes • Itchy nose, eyes and roof of mouth • Sneezing • Stuffy nose • Pressure in the nose and cheeks • Ear fullness and popping • Dark circles under the eyes • Hives

What are the most common allergens?

Pollen from trees, grass and weeds. Allergies that occur in the spring (late April and May) are often due to tree pollen. Allergies that occur in the summer (late May to mid-July) are often due to grass and weed pollen. Allergies that occur in the fall (late August to the first frost) are often due to ragweed. Mold. Mold is common where water tends to collect, such as shower curtains, window moldings and damp basements. It can also be found in rotting logs, hay, mulches, commercial peat moss, compost piles and leaf litter. This allergy is usually worse during humid and rainy weather. Animal dander. Proteins found in the skin, saliva, and urine of furry pets such as cats and dogs are allergens. You can be exposed to dander when handling an animal or from house dust that contains dander. Dust. Many allergens, including dust mites, are in dust. Dust mites are tiny living creatures found


in bedding, mattresses, carpeting and upholstered furniture. They live on dead skin cells and other things found in house dust.

Things that can make your allergy symptoms worse

• Aerosol sprays • Air pollution • Cold temperatures • Humidity • Irritating fumes • Tobacco smoke • Wind • Wood smoke

How can I avoid allergens?

Pollens. Shower or bathe before bedtime to wash off pollen and other allergens in your hair and on your skin. Avoid going outside, especially on dry, windy days. Keep windows and doors shut, and use an air conditioner at home and in your car. Mold. You can reduce the amount of mold in your home by removing houseplants and by frequently cleaning shower curtains, bathroom windows, damp walls, areas with dry rot and indoor trash cans. Use a mix of water and chlorine bleach to kill mold. Open doors and windows and use fans to increase air movement and help prevent mold. Don't carpet bathrooms or other damp rooms and use mold-proof paint instead of wallpaper. Reducing the humidity in your home to 50% or less can also help. You can control your home air quality by using a dehumidifier, keeping the temperature set at 70 degrees, and cleaning or replacing small-particle filters in your central air system. Pet dander. If your allergies are severe, you may need to give your pets away or at least keep them outside. Cat or dog dander often collects in house dust and takes 4 weeks or more to die down. However, there are ways to reduce the amounts of pet dander in your home. Using allergen-resistant bedding, bathing your pet frequently, and using an air filter can help reduce pet dander. Ask your veterinarian for other ways to reduce pet dander in your home. Dust and dust mites. To reduce dust mites in your home, remove drapes, feather pillows, upholstered furniture, non-washable comforters and soft toys. Replace carpets with linoleum or wood. Polished floors are best. Mop the floor often with a damp mop and wipe surfaces with a damp cloth. Vacuum regularly with a machine that has a high-efficiency particulate air (HEPA) filter. Vacuum soft furniture and curtains as well as floors. Install an air cleaner with a high-efficiency particulate or electrostatic filter. Wash carpets and upholstery with special cleaners, such as benzyl benzoate or tannic acid spray. Wash all bedding in hot water (hotter than 130°F) every 7 to 10 days. Don't use mattress pads. Cover mattress and pillows with plastic covers. Lower the humidity in your home using a dehumidifier.

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What medicines can I take to help relieve my symptoms?

Antihistamines help reduce the sneezing, runny nose and itchiness of allergies. They're more useful if you use them before you're exposed to allergens. Some antihistamines can cause drowsiness and dry mouth. Others are less likely to cause these side effects, but some of these require a prescription. Ask your doctor which kind is best for you.


Decongestants, such as pseudoephedrine and phenylephrine help temporarily relieve the stuffy nose of allergies. Decongestants are found in many medicines and come as pills, nose sprays and nose drops. They are best used only for a short time. Nose sprays and drops shouldn't be used for more than 3 days because you can become dependent on them. This causes you to feel even more stopped-up when you try to quit using them. You can buy decongestants without a doctor's prescription. However, decongestants can raise your blood pressure, so it's a good idea to talk to your family doctor before using them, especially if you have high blood pressure. Cromolyn sodium is a nasal spray that helps prevent the body's reaction to allergens. Cromolyn sodium is more helpful if you use it before you're exposed to allergens. This medicine may take 2 to 4 weeks to start working. It is available without a prescription. Nasal steroid sprays reduce the reaction of the nasal tissues to inhaled allergens. This helps relieve the swelling in your nose so that you feel less stopped-up. Nasal steroid sprays are available with a prescription from your doctor. You won't notice their benefits for up to 2 weeks after starting them. Your doctor may prescribe steroid pills for a short time or give you a steroid shot if your symptoms are severe or if other medicines aren't working for you. Eye drops. If your other medicines are not helping enough with your itchy, watery eyes, your doctor may prescribe eye drops for you.

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What are allergy shots?

Allergy shots (also called immunotherapy) contain small amounts of allergens. They're given on a regular schedule so that your body gets used to the allergens and no longer overreacts to them. Allergy shots are only used when the allergens you're sensitive to can be identified and when you can't avoid them. It takes a few months to years to finish treatment, and you may need to have treatments throughout your life.

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Other Organizations

• American Academy of Allergy, Asthma and Immunology http://www.aaaai.org

Source

Written by familydoctor.org editorial staff.

American Academy of Family Physicians

Reviewed/Updated: 09/10 Created: 01/96

Copyright © 1996-2011 American Academy of Family Physicians Home | Privacy Policy | Contact Us

About This Site | What's New | Advertising Policy

Form #6: Smoking: Steps to Help You Break the Habit

Why does it seem so hard to stop smoking?

Smoking causes changes in your body and in the way you act. The changes in your body are caused by an addiction to nicotine. The changes in the way you act developed over time as you bought cigarettes, lit them and smoked them. These changes have become your smoking habit. When you have a smoking habit, many things seem to go along with having a cigarette. These might include having a cup of coffee or an alcoholic drink, being stressed or worried, talking on the phone, driving, socializing with friends or wanting something to do with your hands.

How can I stop smoking?

You'll have the best chance of stopping if you do the following:

• Get ready. • Get support and encouragement. • Learn how to handle stress and the urge to smoke. • Get medication and use it correctly. • Be prepared for relapse. • Keep trying.

How should I get ready to stop smoking?

Set a stop date 2 to 4 weeks from now so you'll have time to get ready. Write down your personal reasons for stopping. Be specific. Keep your list with you so you can look at it when you feel the urge to smoke. To help you understand your smoking habit, keep a diary of when and why you smoke. Using information from this diary, you and your doctor can make a plan to deal with the things that make you want to smoke. Just before your stop date, get rid of all of your cigarettes, matches, lighters and ashtrays. The following guide lists the steps you need to take before, during and after your quit date: Stop Smoking Guide (1-page PDF file. About PDFs).

Immediate reasons to stop

• Bad breath and stained teeth • Bad smell in clothes and hair and on skin • Lower athletic ability • Cough and sore throat • Faster heartbeat and raised blood pressure • Risk of second-hand smoke to people around you • Cost of smoking

Long-term reasons to stop

• Toxic chemicals in cigarette smoke • Risk of lung cancer and many other types of cancer • Risk of heart disease • Serious breathing problems • Time lost working or having fun because you're sick • Wrinkles • Risk of stomach ulcers and acid reflux • Risk of gum disease • Risk of damage to babies of pregnant women who smoke • Setting a bad example for your children

How can I get support and encouragement?

Tell your family and friends what kind of help you need. Their support will make it easier for you to stop smoking. Also, ask your family doctor to help you develop a plan for stopping smoking. He or she can give you information on telephone hotlines, such as 1-800-QUIT-NOW (784-8669), or self-help materials that can be very helpful. Your doctor can also recommend a stop-smoking program. These programs are often held at local hospitals or health centers. Give yourself rewards for stopping smoking. For example, with the money you save by not smoking, buy yourself something special.

What about stress and my urges to smoke?

You may have a habit of using cigarettes to relax during stressful times. Luckily, there are good ways to manage stress without smoking. Relax by taking a hot bath, going for a walk, or breathing slowly and deeply. Think of changes in your daily routine that will help you resist the urge to smoke. For example, if you used to smoke when you drank coffee, drink hot tea instead.

What will happen when I stop smoking?

How you feel when you stop depends on how much you smoked, how addicted your body is to nicotine and how well you get ready to stop smoking. You may crave a cigarette or feel hungrier than usual. You may feel edgy and have trouble concentrating. You also may cough more at first, and you may have headaches. These things happen because your body is used to nicotine. They are called nicotine withdrawal symptoms. The symptoms are strongest during the first few days after you stop smoking, but most go away within a few weeks.

What about nicotine replacement products or medicine to help me stop smoking?

Nicotine replacement products are ways to take in nicotine without smoking. These products come in several forms: gum, patch, nasal spray, inhaler and lozenge. You can buy the nicotine gum, patch and lozenge without a prescription from your doctor. Nicotine replacement works by lessening your body’s craving for nicotine and reducing withdrawal symptoms. This lets you focus on the changes you need to make in your habits and environment. Once you feel more confident as a nonsmoker, dealing with your nicotine addiction is easier. Prescription medicines such as bupropion and varenicline help some people stop smoking. These medicines do not contain nicotine, but help you resist your urges to smoke. Talk to your doctor about which of these products is likely to give you the best chance of success. For any of these products to work, you must carefully follow the directions on the package. It's very important that you don't smoke while using nicotine replacement products.

Will I gain weight when I stop smoking?

Most people gain a few pounds after they stop smoking. Remember that any weight gain is a minor health risk compared to the risks of smoking. Dieting while you're trying to stop smoking will cause unnecessary stress. Instead, limit your weight gain by having healthy, low-fat snacks on hand and being physically active.

What if I smoke again?

Don't feel like a failure. Think about why you smoked and what you can do to keep from smoking again. Set a new stop date. Many ex-smokers did not succeed at first, but they kept trying. The first few days after stopping will probably be the hardest. Just remember that even one puff on a cigarette can cause a relapse, so don't risk it.

Other Organizations

• AAFP's Ask and Act http://www.aafp.org/online/en/home/clinical/publichealth/tobacco/resources.html

• Nicotine Anonymous http://www.nicotine-anonymous.org

• American Lung Association http://www.lungusa.org

• American Cancer Society http://www.cancer.org

• American Heart Association http://www.americanheart.org

• National Cancer Institute http://www.cancer.gov

• Revolution Health Addiction Community http://www.revolutionhealth.com/forums/addiction

Source

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American Academy of Family Physicians

Reviewed/Updated: 01/11 Created: 09/00

Copyright © 2000-2011 American Academy of Family Physicians Home | Privacy Policy | Contact Us

About This Site | What's New | Advertising Policy

Form 6:Smoking and Asthma Don’t Mix Did you know that smoking and asthma are a terrible combina�on?

You probably know that smoking can lead to many health problems—cancer and lung disease

to name a few—but did you know that smoking can make your asthma much worse?

Why does smoking make my asthma worse?

The smoke irritates your lungs, causing them to become more swollen and inflamed. It also

causes your lungs to make lots of s�cky mucus that clogs up your airways and makes it even

harder to breathe.

What will happen if I have asthma and I smoke?

Smoking causes you to cough and wheeze more when you have asthma. You also may cough

more at night, making it hard to sleep and perform well at school and work. You will also

probably have more flare-ups during sports and other ac vi es, meaning you will have to use

your rescue inhaler more. People with asthma who smoke have more asthma a"acks and are

hospitalized more o#en than asthma cs who do not smoke.

What should I do about it?

• Don’t start! Qui&ng smoking is much harder than just saying no to the first cigare"e.

• If you already smoke, talk to your doctor about helping you to Quit Smoking.

• Take ac on! Secondhand smoke (smoke from other people) can make your asthma worse

too. Talk to your friends and family about not smoking around you and encourage them to

quit smoking.

Resources:

• Need help qui'ng? Contact Quit Now NC! (www.quitnownc.org or 919-843-4455).

Form #7: How severe is your asthma?

• Symptoms ≤ 2 days a week • Nighttime awakenings ≤ 2 times a month • No interference with normal activity • Albuterol use (rescue medicine) ≤ 2 days a week • Normal FEV1 between exacerbations,

FEV1 > 80% predicted, FEV1/FVC normal • Exacerbations requiring oral steroids 0-1 times a

year

• Symptoms daily • Nighttime awakenings > 1 time a

week, but not nightly • Some limitation with normal activity • Albuterol use (recue medicine) daily • FEV1 60-80% predicted, FEV1/FVC

reduced 5% • Exacerbations requiring oral steroids

≥ 2 times a year

• Symptoms throughout the day • Nighttime awakenings often 7 times a week • Extreme limitation with normal activity • Albuterol use (rescue medicine) several

times a day • FEV1 <60% predicted, FEV1/FVC reduced

> 5% • Exacerbations requiring oral steroids ≥ 2

times a year

• Symptoms > 2 days a week, but not daily • Nighttime awakenings 3-4 times per

month • Minor limitation with normal activity • Albuterol use (rescue medicine) > 2 days

a week, but not daily and not more than one time on any day

• FEV1 > 80% predicted, FEV1/FVC normal • Exacerbations requiring oral

steroids ≥ 2 times a year

ACE Study Form #7: Dial with Descriptors Page 1 of 1

Step 1

Step 2

Step 3

Step 4 or 5

Use this dial for patients NOT on controller medication to initiate treatment ≥ 12 Years Old

• Symptoms ≤ 2 days a week • Nighttime awakenings ≤ 2 times a month • No interference with normal activity • Albuterol use (rescue medicine) ≤ 2 days a week • FEV1 or peak flow > 80% predicted or personal best • Exacerbations requiring oral steroids 0-1 times a

year • ACT ≥ 20

• Symptoms throughout the day • Nighttime awakenings ≥ 4 times a week • Extreme limitation with normal activity • Albuterol use (rescue medicine) several

times a day • FEV1 or peak flow <60% predicted or

personal best • Exacerbations requiring oral steroids ≥ 2

times a year • ACT ≤ 15

• Symptoms > 2 days a week • Nighttime awakenings 1-3 times a week • Some limitation with normal activity • Albuterol use (rescue medicine) > 2 days

a week • FEV1 or peak flow 60-80% predicted or

personal best

• Exacerbations requiring oral steroids ≥2 times a year • ACT 16-19

Maintain current step or step down if well controlled

for at least 3 months

Step up 1 step and reevaluate in 2-6 weeks

Step up 1-2 steps and reevaluate in 2 weeks

plus consider oral steroid course

Form #7: How well controlled is your asthma?

Use this dial for patients on controller medication and at follow-up visits ≥ 12 Years Old

ACE Study Form #7: Dial with Descriptors Page 1 of 1

Step 6

Step 1

Step 2

Step 3

Step 4

Step 5

Medication Options to Control Asthma 12 Years and Older Medicaid Insurance

*Singulair dose is 5 mg for ages 12-14 and 10 mg for those 15 years and older For Singulair – must complete PA and have documentation of adverse reaction/contraindication to ICS,

growth suppression due to ICS, or be on medium dose ICS needing Singulair to achieve control For Advair and Symbicort – must complete PA indicating pt’s condition is severe enough to warrant ICS/

LABA combination product For severe persistent asthmatics with allergies may combine Advair or Symbicort with Singulair -

listed below as “Additional” Other medications (Xopenex, Flovent, Pulmicort, Asmanex) may

be obtained through PA; Pulmicort is best for pregnancy/lactation

Preferred SABA PRN

Albuterol HFA – 2 puffs

every 4-6 hours prn

Albuterol Neb – 1 neb every 4-6 hours prn

Preferred Low-Dose ICS

Qvar 40 – 1 puff twice a day


Alternative LTRA

*Singulair 5-10 – 1 daily

Less Preferred

Qvar 80 - 1 puff once a day

Qvar 80 - 2 puffs once a day

Preferred - Low-Dose ICS + LABA

Advair HFA 45/21 – 2 puffs twice a day

Advair Diskus 100/50 – 1 puff twice a day

Symbicort 80/4.5 – 2 puffs twice a day

Preferred - Medium-Dose ICS

Qvar 80 – 2 puffs twice a day


Alternative - Low-Dose ICS + LTRA

Qvar 40 – 1 puff twice a day + *Singulair 5-10 – 1 daily


Additional

Low-Dose ICS + LABA + LTRA

Less Preferred

Advair HFA 45/21 – 2 puffs once a day

Advair Diskus 250/50 – 1 puff once a day

Symbicort 80/4.5 – 2 puffs once a day

Qvar 80 – 2 puffs once a day + *Singulair 5-10 – 1 daily

Qvar 80 – 4 puffs once a day

Preferred Medium-Dose ICS + LABA





Alternative Medium-Dose ICS + LTRA


+ *Singulair 5-10 – 1 daily

Qvar 80 – 3 puffs twice a day + *Singulair 5-10 mg – 1 daily

Additional Medium-Dose ICS + LABA + LTRA

Less Preferred


Advair Diskus 500/50 – 1 puff once a day


Preferred High-Dose ICS + LABA


Advair Diskus 500/50 –

1 puff twice a day


Additional

High-Dose ICS + LABA + LTRA

Less Preferred



1 puff once a day





Preferred

Same as Step 5 + Oral Steroid Course

Step 6

Step 1

Step 2

Step 3

Step 4

Step 5

Medication Options to Control Asthma 12 Years and Older

Sliding Scale Insurance

For severe asthmatics with allergies may combine Symbicort with Singulair - listed below as “Additional”

Preferred SABA PRN


every 4-6 hours prn





Alternative LTRA

Singulair 10 – 1 daily

Less Preferred

Qvar 80 - 1 puff once a day


Preferred Low-Dose ICS + LABA


Preferred

Medium-Dose ICS



Alternative Low-Dose ICS + LTRA


+ Singulair 10 – 1 daily

Qvar 80 – 1 puff twice a day + Singulair 10 – 1 daily

Additional

Low-Dose ICS + LABA + LTRA

Less Preferred

Symbicort 80/4.5 - 2 puffs once a day

Qvar 80 - 2 puffs once a day + Singulair 10 - 1 daily





Alternative Medium-Dose ICS + LTRA



Qvar 80 – 3 puffs twice a day + Singulair 10 – 1 daily

Additional

Med-Dose ICS + LABA + LTRA

Less Preferred




Additional High-Dose ICS + LABA + LTRA

Less Preferred


Qvar 80 - 4 puffs twice a day

+ Singulair 10 - 1 daily


Preferred


Step 6

Step 1

Step 2

Step 3

Step 4

Step 5


Commercial Insurance

*Singulair dose is 5 mg for ages 12-14 and 10 mg for those 15 years and older Pulmicort is best for pregnancy/lactation For severe asthmatics with allergies may combine Advair or Symbicort with Singulair -

listed below as “Additional”

Preferred SABA PRN


every 4-6 hours prn


Xopenex HFA – 2 puffs

every 4-6 hours prn

Xopenex Neb (0.042%) – 1 neb 3 times a day prn




Pulmicort Flexhaler 90 –

1 puff twice a day

Pulmicort Flexhaler 180 – 1 puff twice a day

Flovent HFA 44 –

1-2 puffs twice a day

Asmanex 110 – 1 puff once a day


Alternative LTRA

*Singulair 5-10 – 1 daily

Less Preferred

Qvar 80 - 1-2 puffs once a day

Pulmicort Flexhaler 180 - 1-2 puffs once a day

Flovent HFA 110 - 1 puff once a day

Preferred – Low-Dose ICS + LABA




Preferred – Medium-Dose ICS

Qvar 80 – 2-3 puffs twice a day

Pulmicort Flexhaler 180 – 2-3 puffs twice a day

Flovent HFA 110 – 1 puff twice a day


Asmanex 220 – 1-2 puffs once a day

Alternative – Low-Dose ICS + LTRA



Pulmicort Flexhaler 90 – 1 puff twice a day+ *Singulair 5-10 – 1 daily

Pulmicort Flexhaler 180 – 1 puff twice a day + *Singulair 5-10 – 1 daily

Flovent HFA 44 – 1-2 puffs twice a day + *Singulair 5-10 –1 daily

Asmanex 110 – 1 puff once a day + *Singulair 5-10 – 1daily

Asmanex 220 – 1 puff once a day + *Singulair 5-10 – 1 daily

Additional - Low -Dose ICS + LABA + LTRA

Less Preferred

Advair HFA 45/21 - 2 puffs once a day

Advair Diskus 100/50 - 1 dose once a day


Qvar 80 – 2 puffs once a day + *Singulair 5-10 – 1 daily

Pulmicort Flexhaler 180 – 2 puffs once a day + *Singulair 5-10 – 1 daily

Flovent HFA 220 – 1 puff once a day + *Singulair 5-10 – 1 daily






Alternative

Medium-Dose ICS + LTRA

Qvar 80 – 2-3 puffs twice a day + *Singulair 5-10 – 1 daily

Pulmicort Flexhaler 180 – 2-3 puffs

twice a day + *Singulair 5-10 – 1 daily

Flovent HFA 110 – 1 puff twice a day + *Singulair 5-10 – 1 daily



Asmanex 220 – 1-2 puffs once a day + *Singulair 5-10 – 1 daily

Additional

Medium-Dose ICS + LABA + LTRA

Less Preferred


Advair Diskus 250/50 - 1 puff once a day





1 puff twice a day



Less Preferred


Advair Diskus 500/50 -

1 puff once a day



Pulmicort Flexhaler 180 -

4 puffs twice a day

Flovent HFA 220 - 2 puffs twice a day

Preferred


Step 6

Step 1

Step 2

Step 3

Step 4

Step 5


Medicare Community CCRx Insurance

For severe asthmatics with allergies may combine Advair or Symbicort with Singulair - listed below as “Additional”

Preferred SABA PRN


every 4-6 hours prn


Xopenex HFA – 2 puffs

every 4-6 hours prn

Xopenex Neb (0.042%) – 1 neb 3 times a day prn




Flovent HFA 44 –

1-2 puffs twice a day



Alternative LTRA

Singulair 10 – 1 daily

Less Preferred

Qvar 80 - 1-2 puffs once a day

Flovent HFA 110 - 1 puff once a day

Preferred – Low-Dose ICS + LABA




Preferred – Medium-Dose ICS

Qvar 80 – 2-3 puffs twice a day




Alternative – Low-Dose ICS + LTRA



Flovent HFA 44 – 1-2 puffs twice a day + Singulair 10 –1 daily

Asmanex 110 – 1 puff once a day + Singulair 10 – 1daily

Asmanex 220 – 1 puff once a day + Singulair 10 – 1 daily

Additional - Low -Dose ICS + LABA + LTRA

Less Preferred


Advair Diskus 100/50 - 1 dose once a day


Qvar 80 – 2 puffs once a day + Singulair 10 – 1 daily

Flovent HFA 220 – 1 puff once a day + Singulair 10 – 1 daily






Alternative

Medium-Dose ICS + LTRA

Qvar 80 – 2-3 puffs twice a day + Singulair 10 – 1 daily



Flovent HFA 220 – 1 puff twice a day + Singulair 10 – 1 daily



Additional Medium-Dose ICS + LABA + LTRA

Less Preferred


Advair Diskus 250/50 - 1 puff once a day





1 puff twice a day



Less Preferred


Advair Diskus 500/50 -

1 puff once a day



Flovent HFA 220 - 2 puffs twice a day

Preferred


Features

that

matter

to me

Current Plan Option 1 Option 2 Option 3

Form #9: Medication Planner

EMR Sticker

ACE Study Form #9: Med Planner, Page 1 of 1

� Controller medications:

� Prevent asthma symptoms from occurring

� May reduce and/or prevent:

� Inflammation in the airways

� Tightening of muscle bands around the airways

� Do not show immediate results, but work slowly over time

� Are meant to be taken daily, even when you are not having symptoms

� Should NOT be used to relieve immediate asthma symptoms

� Reliever Medications:

� Relieve asthma symptoms once they have started

� Relax the tightened muscle bands around the airways

� Work immediately

� Should be needed very infrequently (no more than twice a week)

� If reliever medications are needed more than twice a week, this

suggests that preventative treatment is inadequate and inflammation

is poorly controlled

FORM #10: GENERAL TYPES

OF ASTHMA MEDICATIONS

ACE Study Form #10: Medication Types, Page 1 of 7

� Beta agonist, such as albuterol, relax the muscles around the airways during bronchospasm which lets the air

move more freely through the airways. Short-acting beta agonist are also sometimes used before exercise to

prevent bronchospasm. Although short-acting beta agonists are the most commonly prescribed asthma

medications, they are also the ones that should he used least often, because they do not help with long-term

control of asthma.

� There are two general types of beta agonist medications:

� The short-acting preparation is called a “rescue” or “reliever medication” because it is used to

rescue you from and provide relief of acute asthma symptoms. Albuterol is short-acting.

� The long-acting preparation is used to prevent bronchospasm and control asthma and is therefore

called a “controller medication.” Serevent® (salmeterol) and Foradil Aerolizer® (formoterol) are

long-acting beta agonists. Long-acting preparations should never be used for rescue or relief of acute

asthma symptoms, such as an asthma exacerbation.

� Short-acting beta agonists such as albuterol (examples: Ventolin, Proventil, or ProAir) are most often

prescribed as aerosols that are breathed into the lungs, using an inhaler or a nebulizer. The inhaler requires

hand-breath coordination to use. If you have trouble using an inhaler, you can use it with a spacer such as the

Aerochamber, which allows the particles of medication to get deep into the lungs. It is a good idea to take

your rescue inhaler with you wherever you go. It is just as important not to take a long-acting beta agonist

like Serevent® or Foradil® with you during the day, since it should only be used once or twice a day on a

regular schedule, for example first thing in the morning and/or in the evening.

� Short-acting beta agonists (also called adrenergic bronchodilators) also come in tablet or liquid form. These

forms of the medications act a little slower and may cause more side effects, but they are still effective. For

emergency relief, a doctor may administer beta agonists by nebulizer.

� The possible side effects of beta agonists include irregular or rapid heartbeat, nervousness, muscle

tremors, insomnia, nausea and vomitting. Overuse of these medications can cause increased bronchial

responsiveness (that is airways that are already “twitchy” due to asthma can become even twitchier or more

responsive).

� Using more than one canister per month of albuterol (or using it more than twice a week) is an

indication that additional (preventive) treatment with an asthma controller medication is needed.

� Needing to use more than 8 puffs of a short-acting beta agonist in one day is another “red flag” that your asth-

ma is out of control. You should not need to use more than 2 puffs per 24 hours except in unusual

circumstances.

ALBUTEROL AND OTHER SHORT-ACTING BETA AGONISTS

ACE Study Form #10: Medication Types

� Inhaled corticosteroids are a very commonly prescribed type of asthma medication for people with

persistent asthma. Although they have a similar name, “corticosteroids” are very different from

“anabolic steroids” which are sometimes used illegally by athletes to increase muscle mass.

� Corticosteroids are the most effective anti-inflammatory medications available. In a cream form, they are

commonly used to treat skin irritations. Because the main problem in the lungs (airways) in asthma is chron-

ic inflammation that narrows the airways and makes breathing difficult, corticosteroids are often used to

treat asthma. Corticosteroids help reduce or prevent swelling (caused by inflammation) and excess mucus in

the bronchial tubes.

� Corticosteroids do not relax the muscles around the bronchial tubes. They will not open the airways

immediately as do bronchodilators such as albuterol. For this reason, corticosteroids may not seem to have

any beneficial effects. However, when taken regularly over time, they reduce the underlying inflammation

and sensitivity of the airways. Corticosteroids treat symptoms that are not affected by the bronchodilators.

For most people with asthma, corticosteroids are the single most effective medication because they break

the inflammatory cycle and reduce the likelihood of future asthma episodes. They are an essential part of

asthma management for children and adults with moderate to severe asthma.

� Inhaled corticosteroids are taken using an inhaler or sometimes a nebulizer. They are “controller med-

ications,” which means they are taken for prevention of symptoms. Unless you have a special instruc-

tions from your physician, don’t start inhaled steroids during an asthma episode; however if you take them

regularly, do not stop taking them when you begin getting symptoms.

� It is important to recognize that common concerns about using oral corticosteroids do not apply to

inhaled corticosteroids because inhaled corticosteroids are not absorbed into the body to any large extent.

� A small portion of individuals experience some local side effects such as:

� Thrush - a yeast infection of the mouth, tongue or throat (causes tiny white spots)

� Hoarseness (sometimes)

� These side effects generally can be avoided by using a spacer, such as Aerochamber, with the inhaler,

rinsing the mouth after each treatment, and keeping the inhaler clean.

� Although very high doses of inhaled corticosteroids have the potential to cause some of the same side effects

as oral corticosteroids, their benefits outweigh any potential negative effect. Even at higher doses, the dose

of inhaled corticosteroids that gets into the body is usually only a tiny fraction of the oral dose, and the side

effects are far less severe.

� Caution: If you develop a severe asthma episode that is unresponsive to your usual medicines, it is

important that you contact a physician immediately. The severe asthma episode may make you unable to

inhale your usual corticosteroids into your lungs, and you may need a “short burst” (five days to two weeks)

of oral corticosteroids.

INHALED CORTICOSTEROIDS


� Oral corticosteroids can be useful in the management of the inflammation associated with asthma. They can

be given either as “short bursts” or as an every-other-day or daily regimen. Oral corticosteroids are more

likely to cause side effects than inhaled corticosteroids because the bloodstream carries them to all parts of

the body, while the inhaled medicines go only to the lungs.

� Oral (systemic) corticosteroids are usually prescribed in “short bursts” of five days to two weeks to treat

acute asthma episodes. Using corticosteroids in this manner is the most effective way to reduce inflamma-

tion and the frequency of future asthma episodes. Oral corticosteroids are available as tab1ets or syrup. In

an emergency situation, the physician may also give corticosteroids by injection or IV. Some examples

include prednisone, Solu-Medrol, OraPred, or Prelone.

� Short bursts (5 days to 2 weeks) of oral corticosteroids, or one-time use in the emergency room, have low

potential for side effects. You may experience passing side effects such as slight weight gain, increased appe-

tite, menstrual irregularities, mood changes, or muscle cramps.

� It is important to finish the whole course of oral corticosteroids that you are prescribed. When steroids are

used as a short burst of a week or so, they can be stopped abruptly. If they are used for more than a week or

two, the dose should be reduced gradually (“tapered off’) so your body can increase its production of natu-

ral steroids again. Health care providers should give specific instructions for tapering the dose.

� Sometimes difficult-to-manage asthma can only be treated with the regular use of daily or alternate-day oral

corticosteroids. Using oral steroids this way is much more likely to cause side effects, and the physician who

prescribes them must balance the risk of side effects against the risk of uncontrolled asthma. Some possible

side effects include glucose intolerance (a reversible form of diabetes), peptic ulcer, bloating, weight gain,

elevated blood pressure, osteoporosis, bruising, glaucoma, and cataracts.

� If routine use of oral corticosteroids is needed, your doctor may recommend that you take the medication

on an alternate-day schedule. If this doesn’t bring your asthma under control, a daily schedule may be

required. The dose should generally be taken in the morning before 8 a.m. with food to mimic the body’s

natural cycle of steroid production and to minimize side effects.

� If you have been taking oral corticosteroids in the previous year, you should tell any other physician,

surgeon, anesthesiologist, or dentist who treats you for any condition.

ORAL (SYSTEMIC) CORTICOSTEROIDS


� Leukotriene modifiers, such as Singulair®, are asthma medications that help to reduce and prevent

inflammation that occurs in the airways of a person with asthma. They belong in the group of “controller”

asthma medications. In asthma and other diseases in which inflammation plays a role, chemicals in the body

called leukotrienes, bind to cells to create the inflammation. Leukotriene modifiers act by blocking the

binding of leukotrienes to the cells, so that the inflammation in the airways of a person with asthma is

reduced.

� Leukotriene modifiers do not open the airways immediately and therefore should not be used for

treating acute asthma episodes. Like inhaled corticosteroids, they do not offer quick relief and may seem

like they are having no effect. This is because they do not relax the tightened muscles and therefore do not,

quickly make you feel that you can breathe better. Instead, they work slowly over time to reduce

inflammation.

� Leukotriene modifiers aren’t as “powerful” anti-inflammatory medications as inhaled corticosteroids, and

don’t work effectively in everyone. Their main value is that they have moderate anti-inflammatory effects,

come in a pill form, and only need to be taken once a day.

� Leukotriene modifiers are generally very safe medications.

LEUKOTRIENE MODIFIERS


� Advair® and Symbicort® are an inhaled asthma medications that combine two separate asthma treatments - an

inhaled corticosteroid and long-acting beta agonist - into one inhaler.

� The corticosteroid component reduces inflammation in the airways. Inhaled corticosteroids are very different

from the anabolic steroids sometimes used illegally by athletes to increase muscle mass. Corticosteroids are very

effective anti-inflammatory medications. For some patients, corticosteroids may be the single most effective

medication in the treatment of moderate or severe asthma, because they break the inflammatory cycle and

reduce the likelihood of future episodes. The other medicine in Advair® or Symbicort® is a long-acting beta

agonist that causes muscle bands surrounding the airway to relax, thereby allowing the airways to open up. By

combining these two controller medications into one, Advair® or Symbicort® treat both the inflammation and

tightened airways that are associated with asthma at the same time. These inhalers come in different strengths in

which the amount of corticosteroid is varied.

� Advair® or Symbicort® is to be taken for the prevention of asthma symptoms, and is not to be used to treat

acute asthma episodes. Acute asthma symptoms should be treated with a short-acting beta agonist such as

albuterol. Advair® or Symbicort® is typically taken twice daily, once in the morning and once in the evening. In

low doses, very little corticosteroid is absorbed into the body, but in higher doses, some is absorbed.

� The side effects of Advair® or Symbicort® are the same as those of the inhaled corticosteroids and long-acting

beta agonists. A small proportion of patients using inhaled corticosteroids experience some side effects such as:

� Thrush - a yeast infection of the mouth, tongue, or throat (causing tiny white spots)

� Hoarseness (sometimes)

� Although very high doses of inhaled corticosteroids have the potential of causing some of the same side effects as

oral corticosteroids, their benefits outweigh any potential negative effect. To diminish the possibility of

experiencing negative effects, Advair® or Symbicort® should be taken at the lowest strength that effectively

controls your asthma.

� The possible side effects of beta agonists include irregular or rapid heartbeat, nervousness, muscle tremors,

insomnia, nausea, and vomiting. Overuse of these medications can cause increased bronchial responsiveness (that

is, airways that are already “twitchy” due to asthma can become even twitchier or more responsive).

� Caution: If you are using Advair® or Symbicort® and you develop a severe episode of asthma that is

unresponsive to your usual medicines, it is important that you contact a physician immediately. The severe asth-

ma episode may make it so that you are not able to inhale the corticosteroids into your lungs, and you may need

a course of oral corticosteroids.

ADVAIR® AND SYMBICORT®

(COMBINATION INHALERS)


Form#10:HowLongWillYourInhalerLast?

� When you first start using a new inhaler, determine how long the canister will last and mark the date on a calendar or on the canister itself.

� Make sure you get your new refill at least one week prior to running out.

� Remember these medications are to be used daily. This will not work for rescue medications used on an as needed basis, such as albuterol.

� Remember to rinse your mouth out after using your inhaler to reduce your risk of getting thrush.

Medication Name Doses per

inhaler 1111 2222 4444 6666 8888

QVAR 100 100 days 50 days 25 days 16 days 12 days

Flovent HFA 120 120 days 60 days 30 days N/A N/A

Pulmicort

Flexhaler 120 120 days 60 days 30 days 20 days 15 days

Asmanex

Twisthaler 120 120 days 60 days N/A N/A N/A

Advair HFA 120 120 days 60 days 30 days N/A N/A

Advair Diskus 60 60 days 30 days N/A N/A N/A

Symbicort 120 120 days 60 days 30 days N/A N/A


Doses Per Day

Did the patient:

� Take the cap off the mouthpiece then shake the inhaler well before each spray?

� Hold the inhaler with the mouthpiece down and exhale fully?

� Put the mouthpiece in their mouth and close their lips around it?

� Push the top of the canister all the way down while breathing in deeply and slowly through their mouth?

� Hold their breath for up to 10 seconds, then breathe normally?

� If using a spacer: Have the mouthpiece of the spacer between their teeth with their lips closed around it during discharge?

Ask the patient:

� If you were really using an inhaler, how long would you wait before taking a second puff? (Answer: 1 or more minutes)

Did the patient:

� Hold the diskus in one hand and put the thumb of their other hand on the thumbgrip?

� Push their thumb away from them as far as it will go until the mouthpiece appears and snaps into position?

� Hold the diskus in a level position with the mouthpiece towards them?

� Slide the lever away from them as far as it will go until it clicks?

� Exhale fully while holding the diskus level and away from their mouth?

� Put the mouthpiece to their lips and inhale quickly and deeply through the diskus?

� Remove the diskus from their mouth, then hold their breath for about 10 seconds, or as long as comfortable?

� Exhale slowly after holding their breath?

� Close the diskus by sliding the thumbgrip back towards them as far as it will go until it clicks shut?

PULMICORT FLEXHALER®

Did the patient:

� Hold the flexhaler upright in one hand then twist the cover and lift it off with the other hand?

� Use their other hand to hold the inhaler in the middle then twist with grip fully in one direction as far as it will go?

� Twist it fully back again in the other direction as far as it will go until a click is heard?

� Turn their head away from the inhaler and exhale?

� Place the mouthpiece in their mouth, close their lips around it, then breathe in deeply and forcefully through the inhaler?

� Hold their breath for 5-10 seconds after inhalation?

� Exhale slowly, NOT into the mouthpiece?

Ask the patient:

� If you were really using a inhaler, how long would you wait before taking a second inhalation? (Answer: 30 seconds or more)

HFA (Albuterol / ICS)

Advair Diskus®

Asmanex Twisthaler®

Did the patient:

� Hold the inhaler upright with the colored base on the bottom?

� While holding the base, twist the cap in a counterclockwise direction to remove the cap?

� Breathe out fully?

� Place the mouthpiece in their mouth, holding it horizontally (on its side), close their lips around it, and take in a fast, deep breath?

� Remove the TWISTHALER from their mouth and hold their breath for about 10 seconds, or as long as comfortable?

� Put the cap back onto the inhaler and turn it in a clockwise direction while gently pressing down until a click is heard?

Form #11: Checklist for proper inhaler use

How to use your inhaler

1. Take the cap off the mouthpiece. 2. Shake the inhaler well before each spray. 3. Hold the inhaler with the mouthpiece down. Breath out through your mouth,

exhaling fully. Tilt your head back slightly to straighten the airways to your lungs.

4. Put the mouthpiece in your mouth and close your lips around it. 5. Hold the inhaler with your thumb on the bottom and your index or middle fin-

ger on top. Push the top of the canister all the way down while you breathe in deeply and slowly through your mouth.

6. Take your finger off the canister. After breathing in all the way, take the inhaler out of your mouth and close your mouth.

7. Hold your breath as long as you can, up to 10 seconds. This allows the medicine to reach deeply into your lungs. Then breathe normally.

8. If more sprays are prescribed, wait 1 minute then shake the inhaler again. Re-peat steps above.

� If you use a spacer, put the mouthpiece between your teeth and seal your lips

around the tube. Using a spacer is a good idea because it helps to get the medi-cine deeper into your lungs.

� If you use a corticosteroid inhaler, rinse your mouth out after use to prevent white spots in the mouth ( “thrush”). Using a spacer can lessen the chances of getting thrush.

How to use your Advair diskus® Dry powder inhaler

1. Hold the DISKUS in one hand and put the thumb of your other hand on the thumbgrip.

2. Push your thumb away from you as far as it will go until the mouthpiece appears and snaps into position.

3. Hold the DISKUS in a level, flat position with the mouthpiece towards you. 4. Slide the lever away from you as far as it will go until it clicks. The DISKUS is now

ready to use. (Every time the lever is pushed back, a dose is ready to be inhaled. This is shown by a decrease in numbers on the dose counter. At this point, avoid releasing or wasting doses by mistake. Do not close the device. Do not play with the lever. Do not advance the lever more than once.)

5. Before inhaling your dose, breathe out (exhale) fully while holding the DISKUS level and away from your mouth. Remember, never breathe out into the mouthpiece.

6. Put the mouthpiece to your lips. Breathe in quickly and deeply through the DISKUS, not through your nose.

7. Remove the DISKUS from your mouth. Hold your breath for about 10 seconds, or as long as comfortable. Breathe out slowly.

8. When you are finished, close the DISKUS. Put your thumb on the thumbgrip and slide the thumbgrip back towards you as far as it will go. The DISKUS will click shut.

� The lever will automatically return to its original position and will reset. The DISKUS

is now ready for you to take your next scheduled dose. REMEMBER:

• Never exhale into the DISKUS. • Never attempt to take the DISKUS apart. • Always activate and use the DISKUS in a level, horizontal position. • Never wash the mouthpiece or any part of the DISKUS. KEEP IT DRY. • Always keep the DISKUS in a dry place.

How to use your Pulmicort Flexhaler®

Priming Your FLEXHALER 1. Hold the inhaler by the grip so that the cover points upward. With your other hand, turn the cov-

er and lift it off. 2. While holding the FLEXHALER upright, use your other hand to hold the inhaler in the middle

(not at the top of the mouthpiece). 3. Twist the grip as far as it will go in one direction then fully back again in the other direction until

it stops (it does not matter which way your turn it first). You will hear a “click” during one of the twisting movements.

4. Repeat Step 3. Your FLEXHALER is now primed and you are ready for your first dose. Loading a Dose 1. Hold your FLEXHALER upright. With your other hand, twist the cover and lift it off. 2. Use your other hand to hold the inhaler in the middle. Do not hold the mouthpiece when you

load the inhaler. 3. Twist the grip fully in one direction as far as it will go. Twist it fully back again in the other direc-

tion as far as it will go (it does not matter which way you turn it first). You will hear a “click” dur-ing one of the twisting movements.

4. Do not shake the inhaler after loading it. Inhaling a Dose 1. Turn your head away from the inhaler and breathe out (exhale). 2. Place the mouthpiece in your mouth and close your lips around it. Breathe in deeply and forceful-

ly through the inhaler. Hold your breath for 10 seconds, or as long as comfortable. 3. You may not sense the presence of any medication entering your lungs. This does not mean that

you did not get the medication and you should not repeat your inhalation. 4. Do not chew or bite on the mouthpiece. 5. Remove the inhaler from your mouth and exhale. Do not blow out into the mouthpiece. 6. If more than once dose is prescribed, repeat the steps above after waiting at least 30 seconds. 7. When you are finished, place the cover back on the inhaler and twist it shut. 8. Rinse your mouth with water after each dose to decrease your risk of getting thrust. Do not

swallow the water.

How to use your asmanex twisthaler

1. Remove the TWISTHALER from its foil pouch and write the date on the cap label. Throw away the inhaler 45 days after this date or when the counter reads “00,” which-ever comes first.

2. Hold the inhaler straight up with the colored base on the bottom. It is important you remove the cap while it is in this position to make sure you get the right amount of medicine with each dose.

3. Holding the colored base, twist the cap in a counterclockwise direction to remove it. As you lift off the cap, the dose counter on the base will count down by one. Remov-ing the cap loads the TWISTHALER with the medicine.

4. Breathe out fully then bring the TWISTHALER up to your mouth with the mouthpiece facing towards you. Place the mouthpiece in your mouth and take in a fast, deep breath. You may not be able to taste, smell, or feel the fine powder after inhaling it. Be sure to not cover the ventilation holds while inhaling the dose.

5. Remove the TWISTHALER from your mouth and hold your breath for about 10 se-conds, or as long as comfortable. Do not breathe out (exhale) into the inhaler.

6. After taking your medicine, wipe the mouthpiece dry if needed then replace the cap by firmly closing the TWISTHALER right away.

7. Be sure the arrow is in line with the dose counter. Put the cap back onto the inhaler and turn it clockwise as you gently press down until you hear a click to let you know the cap is fully closed.

8. Repeat Steps 2-7 if another dose is has been prescribed by your provider. 9. Rinse your mouth each and every time after using your TWISTHALER.

Date

Wheeze

Cough

Chest tightness

Shortness of breath

Sleep problems due to asthma

Asthma symptoms with physical activity

Medications List your medications below and indicate the amount you took each morning and evening

(example: “2 puffs” or “1 pill”)

AM PM AM PM AM PM AM PM AM PM AM PM AM PM

1. _________________________

2. _________________________

3. _________________________

4. _________________________

5. _________________________

_______ _______

_______ _______

_______ _______

_______ _______

_______ _______

_______ _______

_______ _______

_______ _______

_______ _______

_______ _______

_______ _______

_______ _______

_______ _______

_______ _______

_______ _______

_______ _______

_______ _______

_______ _______

_______ _______

_______ _______

_______ _______

_______ _______

_______ _______

_______ _______

_______ _______

_______ _______

_______ _______

_______ _______

_______ _______

_______ _______

_______ _______

_______ _______

_______ _______

_______ _______

_______ _______

Peak flow rate - Morning

Peak flow rate - Evening

Notes

Wheeze None 0 Mild 1 Moderate 2 Severe 3

Cough None 0 Occasional 1 Frequent 2 Continuous 3

Chest tightness None 0 Light 1 Medium 2 Heavy 3

Shortness of breath None 0 Some 1 Frequent 2 Continuous 3

Sleep problems due to asthma

None 0 Awake 1 time with wheeze or cough 1

Awake 2-4 times with wheeze or cough 2

Awake most of the night with asthma symptoms 3

Asthma symptoms with physical activity

None 0 Can be active for short period of time before symptoms occur 1

Can walk only 2 Missed school/work,

stayed indoors 3 Symptom Severity Key

Form #12: One Week Asthma Diary

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