PATIENT INFORMATION FORM "I am going to ask you a number of questions about your asthma. The set of questions is somewhat long, but I will try to move through it fairly quickly so that we can complete this meeting in a reasonable amount of time. I may need to bring us back to the questions if we get off track, but if there is something I'm not asking about that you feel is really important to tell me, please let me know." ASTHMA BOTHER Question Probe Notes on patient responses How much does asthma get in the way of doing what you want to do or living the way you want to live -- how does it affect your daily life? Are there one or two things that you just mentioned that bother you the most, or that you would most like to change? How long have you had asthma? SYMPTOMS Probe for information about: activity level your finances your work and/or home life, your relationships with friends/ family how you think about or see yourself anything else? Question Probe Notes on patient responses In the past 4 weeks, did your asthma wake you up at night? (Includes asthma related coughing) In the past 4 weeks, did you miss any normal daily activity because of your asthma? How often do experience episodes in which your asthma is especially bad (we call these "asthma exacerbations" or flare-ups)? How often? How often? Years Awakened at night? Y N Frequency or # times? Miss daily activity? Y N Frequency or # times? Have you ever had to go to the ER or urgent care during an asthma exacerbation? Have you ever been hospitalized because of asthma? Do you experience a cough with your asthma? How well-controlled you do think your symptoms are? [go to control meter] [If yes] When was the last time? [If yes] When was the last time? How often? Can you tell me what the cough is like? Have patient draw arrow on Handout 1: "How wellcontrolled is your asthma?" to indicate perceived control. 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 (also called post-nasal drip) most of the year? Has your health care provider told you that you have chronic sinus problems? 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? Does food sometimes come up into your throat? In the past 4 weeks, have you had coughing, wheezing, or shortness of breath that was not relieved by taking albuterol? Y N Y N Y N Y N Y N Y N # Y Y N Y N Y N # Y FORM SDM-R1 Page 1 of 4
MEDICATION USE CONTINUED Question Probe Notes on patient responses Many people have a hard time taking their controller medication on the prescribed schedule. How often do you miss taking a dose of (any of) your controller medication(s) (your [or ])? 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 any controller medications you use (your [or ], or asthma controllers you have used in the past)? Have you tried taking more of any controller medications than what was prescribed by your doctor? What is the reason? (e.g. forgetting, being tired or busy, deciding not to) What happened? Did you continue to take a decreased amount or stop altogether? How did that work out? 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 it? [Probe if reported problems are unlikely to be attributable to the medication] What did you do about that? Any other asthma medications that gave you problems? How do [would] you feel about taking asthma controller medications (your [and ]) on a regular basis? Are there other things that [would] bother you about taking asthma medication every day? ASK ONLY PATIENTS WHO DO NOT TAKE ASTHMA CONTROL MEDICATIONS OR Short Acting Beta Agonists REGULARLY: What are the worst things about taking asthma medication every day? Do you believe that taking your [controller] meds more regularly would make any difference in your asthma? Are you concerned about side effects of any asthma medications (ones you take, or others)? What things are you concerned about? Probe further if side effects mentioned have not been documented FORM SDM-R1 PAGE 3 of 4
MEDICATION USE If necessary for this section, show pictures on the Asthma Controllers/Relievers poster What are your current PRESCRIPTIONS for your asthma medications? Let s start with albuterol. For each medication: How often is it supposed to be taken? (Inhaled meds) How many puffs each time? How many days in the last week did you take your [insert name]? (Inhaled meds) How many puffs do you usually take? How do you think this medication works on your asthma? Med 1: ALBUTEROL Rx: # days taken last week: Usual # puffs: How patient thinks it works: Med 2: Rx: # days taken last week: Usual # puffs: How patient thinks it works: Med 3: Rx: # days taken last week: Usual # puffs: How patient thinks it works: Question Would you show me how you use your inhaler? [Examine technique, using appropriate Skills Checklist " below. Note errors, but do not correct technique until "Wrap up" section later in the session.] 1. Did the patient shake the inhaler vigorously (5-10 seconds) prior to use? 2. Did the patient exhale fully prior to inhalation? 3. Did the patient tip her/his chin up prior to inhalation? 4. Was the inhaler held level and discharged with the index or middle finger on top of the medication canister and the thumb supporting the inhaler's base? 5. *Did the patient have his/her lips closed and the spacer between his/her teeth during discharge? 6. Did the patient inhale slowly and deeply after inhaler discharge? 7. Did the patient hold his/her breath for 6 to 10 seconds after inhalation? 8. ASK THE PATIENT: If you were really using an inhaler, how long would you wait before taking a second puff? CHECK YES IF ANSWERED ONE OR MORE MINUTES, OTHERWISE CHECK NO. * If a spacer is not used: was the inhaler held 2-5 cm. (1-2 in.) from the patient's open mouth during discharge? FORM SDM-R1 Med 4: Rx: # days taken last week: Usual # puffs: How patient thinks it works: PAGE 2 of 4 Notes on patient technique MDI CHECKLIST SEREVENT & ADVAIR DISKUS CHECKLIST TURBUHALER CHECKLIST 1. Did the patient hold the DISKUS in one hand and use the thumb of the other hand to unveil the mouthpiece? 2. Did the patient hold the DISKUS in a level, horizontal position with the mouthpiece facing him/her? 3. Did the patient slide the lever away from him/her as far as it would go until it clicked? 4. Did the patient exhale while holding the DISKUS level and away from his/her mouth? 5. Did the patient put the mouthpiece to his/her lips and inhale quickly and deeply through his/her mouth? 6. Did the patient hold his/her breath for about 10 seconds after inhalation? 7. Did the patient exhale slowly after holding his/her breath? 8. Did the patient close the DISKUS by sliding the thumbgrip back towards him/her as far as it would go until it clicked shut? 1. Did the patient hold the turbuhaler in the upright position while loading the dose? 2. Did the patient twist the brown grip fully to the right and twist it back fully to the left until there was an audible click? 3. Did the patient turn his/her head away from the turbuhaler while exhaling prior to inhaling the dose? 4. Was the turbuhaler held in the horizontal position when the patient inhaled? 5. Did the patient have his/her lips closed and the mouthpiece between his/her teeth during the inhalation? 6. Did the patient inhale deeply and forcefully so as to activate the flow of medication? 7. Did the patient hold his/her breath for 5 to 10 seconds after inhalation? 8. Did the patient exhale slowly through pursed lips? 9. ASK THE PATIENT: If you were really using an turbuhaler, how long would you wait before taking a second inhalation?
ALTERNATIVE TREATMENTS Question Probe Notes on patient responses Have you ever tried any things other than prescription medications to help with your asthma: 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 medications or did you try to use them as an alternative to taking medication? ENVIRONMENTAL TRIGGERS Question Probe Notes on patient responses Are there different times of the year that your asthma is better of worse? When is it worse? Worse at times? Y N When? Are there certain things in your surroundings that you know affect your asthma? What changes have you made in your surroungings in order to avoid asthma symptoms? Has that been helpful? Are there changes you think you should make that you haven t decided to or haven t been able to do? What are they? What gets in the way of these changes? Are you a smoker? [if yes] Have you tried to quit? I will give you some information on Kaiser's programs to help people quit and I want to encourage you to take advantage of them. This is particularly important because you have asthma. Check box indicating that you have recommended cessation and provided cessation resources for smokers. FORM SDM-R1 PAGE 4 of 4
FORM SDM-HO1A How well controlled is your asthma?
How well controlled is your asthma? Symptoms more than once a week but not daily Nighttime symptoms more than twice a month but not weekly Normal lung function between episodes Symptoms daily Asthma episodes may affect activity & sleep Nighttime symptoms weekly or more often FEV1 60-80% of predicted OR PEF 60-80% of personal best Symptoms less than weekly Brief asthma episodes Nighttime symptoms no more that twice a month Normal lung function between episodes Symptoms daily Frequent asthma episodes Frequent nighttime asthma symptoms FEV1 < 60% predicted OR PEF < 60% of personal best FORM SDM-HO1B
MEDICATION OPTIONS TO CONTROL ASTHMA OPTIONS MILD PERSISTENT ASTHMA FEATURES QVAR 40 1-2 puffs twice a day QVAR 80 1 puff twice a day Pulmicort 1 puff twice a day Aerobid 1-2 puffs twice a day QVAR 80 2-3 puffs once a day Flovent 110 2 puffs once a day Flovent 220 1 puff once a day Pulmicort 2-3 puffs once a day Aerobid 2-4 puffs once a day Singulair 1 10-mg pill once a day Sustained release theophylline Gives optimal control Maximizes convenience Probably provides less control; not a corticosteroid OPTIONS QVAR 80 2-3 puffs twice a day Flovent 110 2-3 puffs twice a day Flovent 220 1 puff twice a day Pulmicort 2-3 puffs twice a day Aerobid 3-4 puffs twice a day MODERATE PERSISTENT ASTHMA QVAR 80 2-3 puffs twice a day + Serevent Diskus 1 inhalation twice a day Flovent 110 2-3 puffs twice a day + Serevent Diskus 1 inhalation twice a day Flovent 220 1 puff twice a day + Serevent Diskus 1 inhalation twice a day Pulmicort 2-3 puffs twice a day + Serevent Diskus 1 inhalation twice a day Aerobid 2-4 puffs twice a day + Serevent Diskus 1 inhalation twice a day Advair 250/50 two inhalations per day FEATURES Gives optimal control QVAR 80 2-3 puffs twice a day Flovent 110 2-3 puffs twice a day Flovent 220 1 puff twice a day Pulmicort 2-3 puffs twice a day Aerobid 2-4 puffs twice a day QVAR 80 3-4 puffs once a day + Serevent Diskus 1 inhalation once a day Flovent 110 4 puffs once a day + Serevent Diskus 1 inhalation once a day Flovent 220 2-3 puffs once a day + Serevent Diskus 1 inhalation once a day Pulmicort 3-4 puffs once a day + Serevent Diskus 1 inhalation once a day Aerobid 4 puffs once a day + Serevent Diskus 1 inhalation once a day Advair 500/50 one inhalation per day Inhaled corticosteroid plus another controller in tablet form; not a Long Acting Beta Agonist. Once a day; Inhaled corticosteroid plus a Long Acting Beta Agonist - maximizes convenience QVAR 80 3-4 puffs once a day Flovent 110 4 puffs once a day Flovent 220 2-3 puffs once a day Pulmicort 3-4 puffs once a day Aerobid 4 puffs once a day Inhaled corticosteroid plus another controller in tablet form; once a day; not a Long Acting Beta Agonist. QVAR 80 4 puffs once a day Flovent 110 2-3 puffs once a day Flovent 220 2-3 puffs once a day Pulmicort 3-4 puffs once a day Aerobid 4 puffs once a day Sustained release theophylline 1 Probably provides less control SEVERE PERSISTENT ASTHMA OPTIONS QVAR 80 >4 puffs twice a day + Serevent Diskus 1 inhalation twice a day Flovent 110 >4 puffs twice a day + Serevent Diskus 1 inhalation twice a day Flovent 220 >2 puffs twice a day + Serevent Diskus 1 inhalation twice a day Pulmicort >4 puffs twice a day + Serevent Diskus 1 inhalation twice a day Aerobid >5 puffs twice a day + Serevent Diskus 1 inhalation twice a day Advair 500/50 two inhalations per day Flovent 220 4 puffs once a day + Serevent Diskus 1 inhalation twice a day FEATURES Gives optimal control Provides less control. The inhaled corticosteroid only is taken once a day. FORM SDM-R4 rev 6/17/03 Prescribing Guidelines adapated from the National Asthma Education and Prevention Program NAEPP Expert Panel Report: Guidelines for the Diagnosis and Management of Asthma - Update on Selected Topics 2002.
My Asthma Treatment Goals is/are: Activities: Other concerns: Features of Asthma Medications Control over inflammation and symptoms Side effects Cost Convenience FORM SDM-HO2
Medication Planner Features that matter to me How these options measure up Current Plan Option 1 Option 2 Option 3 Option 4 FORM SDM-HO5
Asthma Management and Action Plan Controller Medicines (Use every day to stay healthy) How much to take Date: Patient Name Care Provider's Name: Care Provider's Phone #: Other Instructions How often (such as spacers/masks, nebulizers) times per day EVERY DAY! times per day EVERY DAY! times per day EVERY DAY! times per day EVERY DAY! Quick-Relief Medicines How much to take How often Other Instructions Take ONLY as needed NOTE: If this medicine is needed often ( times per week), call physician. Green Zone I feel good No asthma symptoms, even when I'm active Peak flow above 80% Yellow Zone I do not feel good and have asthma symptoms that may include: Wheezing Tight chest Cough Shortness of breath Awakening due to coughing or difficulty breathing Decreased ability to do usual activities My peak flow is 50-80% _ _ Red Zone I feel awful! Warning signs may include: Wheezing, coughing, or difficulty breathing continues or worsens even after taking everyday and extra "yellow zone" medications listed above Unable to sleep or do activites because of trouble breathing My peak flow is below 50% Danger! Get help immediately PREVENT asthma symptoms every day: Take my controller medicines every day. Before exercise, take puffs of. Avoid things that make my asthma worse Avoid exposure to tobacco smoke CAUTION. Take action by continuing to take asthma controller medicines every day AND: Take Albuterol: puffs If I do not feel good and still have symptoms within one hour, then: Increase Add Call MEDICAL ALERT! Get Help! Take until I get help Take Call Call 911 if you have trouble walking or talking due to shortness of breath, OR lips or fingernails are grey or blue. I have discussed the treatment options for my asthma with my Care Manager. We have agreed that I will try the treatment regimen outlined above. I will inform my Asthma Care Manager about changes in my asthma symptoms so that adjustments can be made as needed. Signed: This plan is adapted from an action plan developed by the Regional Asthma Management and Prevention (RAMP) Initiative, a program of the Public Health Institute (www.rampasthma.org).