Colorado’s asthma care coordinators discovered that children were refilling their medications at the lowest rate in the region. The group works alongside physicians and staff to provide education and outreach to Kaiser Permanente members with asthma or chronic obstructive pulmonary disease.

Inhaled corticosteroids help control asthma by reducing inflammation and mucus production. Asthmatics who use the meds daily experience fewer attacks, use their emergency medicine less and make fewer visits to the emergency room.

There are some common threads among patients, who don’t refill their prescriptions. These include the costliness of inhalers, the fact some patients are reluctant to take a steroid, and often patients stop medication when they start to feel better.

“It took us a while to identify the most important thing our UBT could do,” said Cindy Lamb, RN, an asthma care coordinator and member of UFCW Local 7. “It was definitely a learning process.”

So, the asthma coordinators decided to improve the refill rate through an outreach program and targeted members ages 5-17. They made phone calls to five members a week who had not refilled their prescriptions in more than four months. As part of the discussion they included talking points about the benefits of inhaled corticosteroids. They used trackers and scoreboards to monitor the outreach and keep everyone informed.

The seven asthma care coordinators were spread throughout the region, so they held weekly phone huddles to share progress and best practices. They highlighted the convenience of the mail order pharmacy, and provided members with prescription refill numbers as well as the telephone number to the pharmacy. This information helped patients refill their medications more promptly.

The team also had communicated regularly with pediatric physicians and other staff by phone, conversations, meetings, and email.

None of it happened overnight, but the team discovered the collaborative effort really helped the process. In all, they reached 1,100 patients.

“Give the process the time it needs,” said Asthma Care Coordination manager Leah Brines. “Resist the temptation to come up with solutions for the team and instead, guide the conversation, and encourage participation and discovery. The team, given the time and confidence, will find the solution.”