Care Coordination, Action Plans, and Follow-up
Care Coordination
Core concepts
Care coordination deliberately links patient, family, primary care, specialist, school, pharmacy, payer, and community resources across settings. Know the roles: asthma care coordinator or case manager, community health worker, school nurse, pharmacist. Understand referral to an asthma specialist (for example Step 4 or higher therapy, Step 3 plus an exacerbation, poor control despite good adherence, or need for immunotherapy or biologics), closed-loop referral, and documentation.
Practical content
- School: send a copy of the written action plan, medication authorization forms, and self-carry permission; respect FERPA and HIPAA boundaries.
- Transitions: the period after an ED visit or hospitalization is high risk, so arrange follow-up within 2-7 days, reconcile medications, and review technique.
- Social determinants: housing, cost, transportation, insurance, caregiver work schedules, language. Screen and connect to resources.
- Quality metrics: an asthma medication ratio (controller fills divided by total asthma fills) of 0.5 or higher suggests adequate controller use; also track ED use and absenteeism.
The traps
Questions test role boundaries and communication loops, not who "owns" the patient. A referral is not coordination until the result returns and is acted on. Do not assume the school has the plan because a parent said so; confirm receipt.
Worked example
A patient is discharged after an ED visit for asthma: schedule follow-up within 2-7 days, send the updated action plan to the school nurse, reconcile inhalers with the pharmacy, and confirm the family can afford the ICS.
Rule of thumb: every handoff needs a sender, a receiver, and a confirmation.
Action Plans and Follow-up
Core concepts
A written asthma action plan translates control status into action. It has three zones: green (doing well), yellow (getting worse), red (medical alert). Plans may be symptom-based, peak-flow-based (requires the patient's personal best), or both. Each plan must specify drug, dose, and frequency, when to call the clinician, and when to call 911 or go to the ED, and must be shared with school and caregivers in the family's language at every visit.
Follow-up rhythm
- Routine review every 1-6 months once control is achieved, more often during adjustment.
- Reassess within 2-6 weeks after starting or changing therapy, and within 2-7 days after an ED visit or hospitalization.
- Step down after at least 3 months of well-controlled asthma; step up if not well controlled after checking adherence and technique.
- Annual influenza vaccination and current immunizations.
The traps
Yellow-zone instructions are specific: increase reliever and call if no improvement, not "double the controller." Red zone means emergency action, not a routine call. Never build a peak-flow plan without a documented personal best, because using predicted values is a classic error. An expired or unshared plan is not a plan.
Worked example
A patient's personal best PEF is 400 L/min and today's PEF is 260 (65% of best) with nighttime cough: yellow zone, so reliever, per-plan adjustment, and same-day clinician contact. Below 200 (50%) is red zone and requires emergency care.
Rule of thumb: green 80% or more of personal best, yellow 50-79%, red below 50%, and every zone names a medication and a phone number.