Breakout Session 2B : Evaluation and Management of Patients with Uncontrolled Asthma

1. Steven Chen, PharmD Associate Dean for Clinical Affairs, USC School of Pharmacy Keith Funjinaga, PharmD Director of Pharmacy, Inland Behavioral and Health Services Breakout Session 2B:Evaluation and Management of Patients with Uncontrolled Asthma

2. FRAMING AND PURPOSE The intent of this session is to apply Comprehensive Medication Management to patients with uncontrolled asthma, leading to safe and rapid control

3. WHAT YOU WILL HEAR… Evaluation of the asthma patient Testing Assessment Plan for rapid control Asthma Action Plan

4. WHO’S IN THE ROOM? Health system leaders Health plans leaders Quality improvement experts Pharmaceutical industry Pharmacy technicians Physicians Nurses Community-based pharmacists Ambulatory care pharmacists Other

5. REQUEST ASSERTIONS Asthma exacerbation = treatment failure Patients with asthma who understand the underlying cause of asthma, the role their medications play, the use of devices, and receive an asthma action plan will markedly reduce risk of exacerbations. Asthma Control can be achieved in 4 visits. Commit to providing a comprehensive assessment of your asthma patient at every visit, not assuming that previously mastered knowledge / skills persist.

6. Breakout Format Review of materials / resources Pair up: PharmD and “patient” PharmD conducts CMM evaluation Reconvene: What went well? What was challenging? Did you identify and resolve key medication-related problems?

7. Introduction Introduce yourself as Dr. ­­­______________, clarify that you're a Doctor of Pharmacy / Advanced Practice Pharmacist / Student Pharmacist and the purpose of the visit (reason patient was referred / self-referred and “…to make sure your medications are working the best for you while avoiding side effects and other problems”)

8. Assessment of knowledge and top concerns of patient High-level evaluation of your patient’s disease state knowledge and primary concerns Avoid sounding like interrogating, questioning competency “Can you tell me what you’ve been told about your asthma? “How are you doing with your asthma?“ “What goals do you have for treating your asthma?” “Do you have any worries or concerns about asthma?”

9. Assessment of knowledge and top concerns of patient Sample questions to avoid: “What do you know about asthma?” “Are you aware that your asthma is in really bad shape?“ “Don’t you want to get your asthma under full control? “Aren’t you worried about what uncontrolled asthma can do to you?” Respond to patients concerns With permission, provide supplemental and accurate information Aim for engagement (taking personal interest) and activation (motivated to take action) using Motivational Interviewing techniques whenever possible

10. Asthma Symptom Evaluation In the past 4 weeks… “How many times per week did you have asthma symptoms (cough, wheeze, chest tightness, shortness of breath) in the DAYTIME?” (>2) “How many times did you wake due to asthma at NIGHT?” (Any) “How many times did you need your rescue inhaler each week?”(>2) “Does asthma prevent you from participating in any activities?” (Y) Sx Control: 0 = Well-controlled 1-2 = Partly Controlled 3-4 = Uncontrolled

11. Asthma Evaluation Acute care utilization Self-monitoring: Peak flow levels (dates, times, values), rescue inhaler diary if available Self-care: Do habits compliment medications? Nutrition Exercise Weight management needs Smoking

12. Asthma Evaluation “What triggers / sets off your asthma symptoms?” Inquire about risk factors if not documented, e.g., GERD, allergic rhinitis, anxiety, depression, NSAIDs Confirm diagnosis: Did the patient have asthma as a child? Is the patient at risk for COPD (e.g., smoking history, age)?

13. Asthma Medication Evaluation Evaluate all medications (including Rx, OTC, supplements, herbals): “Can you tell me what you were told about the purpose of (medication)?” “How do you take it (when, with food, etc)?” “Did you take your medication today / last night (latest dose)? Do you ever forget or skip taking it? How often? Is it just because you forget, or is there another reason?” “Do you have any problems or concerns with any of your medications?” Screen for common side effects Have patient demonstrate use of all devices Are test results available to ensure all medications are being used safely & effectively? Are all medications evaluated for appropriateness and effectiveness (selection, dosing), safety (given other meds and comorbidities), and ability for patient to take / use as directed (dexterity, administration, access / affordability)?

14. Asthma Management Approach: E.S.C.APE in 4 Visits E: Evaluate & correct asthma knowledge and use of medications, step up treatment if needed (2-7 days after exacerbation, otherwise 1-2 wks) S: Step-up meds (add or increase doses), manage triggers (2-4 wks) C: Continue dose titration, reinforce proper use of devices (2-4 wks) APE: Action Plan Established based on personal best peak flow when stable https://ginasthma.org/wp-content/uploads/2019/01/GINA-Implementation-Toolbox-2019.pdf

17. Breakout Format Review of materials / resources Pair up: PharmD and “patient” PharmD conducts CMM evaluation

18. Breakout Format Review of materials / resources Pair up: PharmD and “patient” PharmD conducts CMM evaluation Reconvene: What went well? What was challenging? Did you identify and resolve key medication-related problems?

19. Asthma Breakout Takeaways • E.S.C.APE in 4: • Evaluate • Step-up • Continue • Action Plan Established • Motivate, engage, education (devices!), activate • Check-in every 3-6 months, even when under control