Vermont Department of Health - Asthma Program and 1 more...less...


# of patients who received follow up asthma education after an ED discharge through the MAPLE plan intervention

82Q4 2018

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Story Behind the Curve

Last updated: May 2020

Author: Asthma Program, Vermont Department of Health

The MAPLE plan is a project designed to increase the delivery of asthma education and patient self-management after hospital discharge. Initially, the MAPLE plan was being implemented in Rutland at the Rutland Regional Medical Center (RRMC).  This program became the model for the Springfield Health Center Systems (SMCS), who started their 2017 and reaching 9 surrounding clinics.  Patients with a recent Emergency Department visit or hospitalization due to asthma, are flagged for outreach and scheduled for telephone call backs to check on the patient's asthma, ensure medication adherence, and to provide reinforcing self-management education and coaching.  Originally, the patient call-backs occurred through RRMC’s Pulmonary Rehab Department, but has since been integrated into the central hospital call-back center.  This has caused a decrease in those attributed to the RRMC's Maple Plan data records.  Furthermore, both medical systems are undergoing significant transitions in staffing, structure, and funding, which we anticipate will lead to reductions in call backs in the future.  The Vermont Asthma Program is working with partners to further enhance capacity and use of electronic health records to help flag patients for follow-up, including monitoring asthma control at each point of contact. 

  • Blueprint for Health is a partner that works with the Vermont Asthma Program on educating community health teams on asthma education and tools available to improve self-management, including Asthma Action Plans and Healthier Living Workshops that support improving asthma management.
  • Rutland Regional Medical Center is a partner that works with the Vermont Asthma Program on home visiting programs, the MAPLE hospital discharge protocol and community education.
  • Vermont Department of Health Offices of Local Health are partners that work with the Vermont Asthma Program to disseminate asthma action plans and reach local communities
  • Asthma Advisory Panel is a partner that works with the Vermont Asthma Program on developing strategic goals and relationships.
  • University of Vermont: Pediatrics is a partner that works with the Vermont Asthma Program on expanding access and delivery of supplementary asthma self-management education to those with uncontrolled asthma and severe persistent asthma to prevent asthma-related emergency department visits and hospitalizations.
What Works

In 2007, the National Asthma Education and Prevention Program (NAEPP), coordinated by the National Heart, Lung, and Blood Institute (NHLBI), released its third set of clinical practice guidelines for asthma. The Expert Panel Report 3—Guidelines for the Diagnosis and Management of Asthma (EPR-3) reflects the latest scientific advances in asthma drawn from a systematic review of the published medical literature by an NAEPP-convened expert panel. It describes a range of generally accepted best-practice approaches for making clinical decisions about asthma care. The guidelines are specific about the necessity of asthma self-management education to reduce healthcare utilization.

Action Plan

The main strategy utilized by the program is to empower the patient to self-manage and provoke awareness to the chronic condition. Interventions through the program are focused on the most recent data available including asthma prevalence, hospitalizations and emergency department visits attributed to asthma in a given geographical location.

September 2015- December 2016: Evaluation findings at RRMC will be utilized to coordinate and revise the program for future locations. Further, Springfield’s Community Health Team has gathered recent evaluation findings at RRMC to help implement their own plan. The Springfield plan will include both adult and pediatric patients and install call back services via primary care offices in the Springfield Health System.

Scorecard Result Container Indicator Measure Action Actual Value Target Value Tag S R I P PM A m/d/yy m/d/yyyy