AW Medical PPS
Asthma
AW Medical PPS will actively seek to prevent, maintain and/or improve the health status of patients
who are at risk for and/or have been diagnosed with Asthma. In this model the Primary Care office shall
be the “Gatekeeper” for all referrals and treatments.
I. RATIONALE/ OBJECTIVE
This program is conceptually based upon the NYC Department of Health and Mental Hygiene’s and the
Fund for Public Health NY’s Medication Adherence Project. However, it is AW Medical’s intent to utilize
its primary care providers as the overall coordinator of care for patients with Asthma thus enhancing
their ability to identify potential catastrophic coexisting conditions early in their disease process. The
primary care office will further positively influence and implement the strategies necessary to influence
patient non-compliance due to health literacy, cultural values, language, and side effects of treatment.
II. CLASSIFICATION AND DIAGNOSIS
The diagnosis of asthma is a clinical one; there is no standardized definition of the type, severity
or frequency of symptoms, nor of the findings on investigation. The absence of a gold standard
definition means that it is not possible to make clear evidence based recommendations on how
to make a diagnosis of asthma. Emphasis must therefore be placed on intense history taking.
The differential diagnosis, the natural history of wheezing illnesses, the ability to perform
certain investigations and their diagnostic value, are all influenced by age.
II. MANAGEMENT
A. Implementation (The Team)
People with Asthma should receive medical care from a team that may include physicians and physician
extenders, nurses, dietitians, pharmacists, and mental health professionals. It is essential in this
collaborative and integrated team approach that patients with Asthma assume an active role in their
care. The management plan should be formulated as a collaborative therapeutic alliance among the
patient and family, the physician, and other members of the health care team.
The team will rely on other provider types to help in the care of the Patient including Laboratories, DME
suppliers, Home Care, Housing, and Behavior Health.
III. REFERRALS
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The primary care physician will coordinate all 1st level referrals for patients diagnosed with
Asthma or patients requiring differential testing to confirm the diagnosis of Asthma. The
indications for referral to a partner provider include the following.
A. Indications for specialist referral in children
1. Diagnosis unclear or in doubt
2. Symptoms present from birth or perinatal lung problem
3. Excessive vomiting or posseting
4. Severe upper respiratory tract infection
5. Persistent wet or productive cough
6. Family history of unusual chest disease
7. Failure to thrive
8. Nasal polyps
9. Unexpected clinical findings eg focal signs, abnormal voice or cry, dysphagia,
inspiratory stridor
10. Failure to respond to conventional treatment (particularly inhaled corticosteroids
above 400 mcg/day or frequent use of steroid tablets)
11. Parental anxiety or need for reassurance
B. Indications for specialist referral in adults
1. Diagnosis unclear
2. Unexpected clinical findings (ie crackles, clubbing, cyanosis, cardiac disease)
3. Unexplained restrictive spirometry
4. Suspected occupational asthma
5. Persistent non-variable breathlessness
6. Monophonic wheeze or stridor
7. Prominent systemic features (myalgia, fever, weight loss)
8. Chronic sputum production
9. CXR shadowing
10. Marked blood eosinophilia (>1 x 109/l)
11. Poor response to asthma treatment
12. Severe asthma exacerbation
IV. ASTHMA ACTION PLAN
All persons with Asthma should receive a written asthma action plan. Asthma is a complex,
potentially life-threatening condition. Treatment instructions, which include using multiple
medications, responding to various stages of symptoms and making environmental changes,
must be documented in the patient’s record and the patient should get a copy. This asthma
Asthma - November7, 2014
action plan will cover routine or daily treatment as well as recognizing and handling worsening
symptoms.
 Implement patient and family Asthma action plan.
 Implement school action plan.
V. POINTS OF DISCUSSION TO BE ADDRESSED BY EACH CARE TEAM MEMBER:
A. What is process, in which you will engage the AW Medical patient?
B. Are you able to accept referrals from AW Medical PPS?
C. Are you willing and able to interface with the AW Medical Platform for integration?
D. Our staff will reach out to you to schedule an appointment for our patient; can your organization
accommodate same day referrals if needed?
E. Will your organization commit to communicating information back to the AW Medical PPS in a
timely manner regarding treatment of our patient?
F. How will you handle forward referrals, if after assessing the patient that patient needs service from
another provider?
G. What is your protocol/process for intervention/treatment? Please provide a summary protocol that
your organization will use to evaluate and treat the patient.
H. How will you handle forward referrals, if after assessing the patient you identify that the patient
needs service from another provider?
Asthma - November7, 2014