Application Guidelines & Evaluation Criteria

Content

The National Environmental Leadership Award in Asthma Management recognizes asthma organizations that serve in leadership roles in their communities to promote, coordinate, ensure delivery of, and sustain comprehensive asthma care that includes environmental interventions for people who need them.

Past award winners have included health care plans, health care providers, public health organizations, and community-based organizations. Many types of organizations can demonstrate leadership and excellence through their efforts to build, scale, and sustain coordinated community asthma care systems. You can learn more about the variety of past award winners and explore past winners’ exemplary work—including some of the distinguishing features that helped their applications standout—in our Award Winners Hall of Fame.

To qualify for the award, applicants must serve in a significant leadership and coordination role in asthma care and service delivery in their communities. All applicants must demonstrate and describe their contributions and the contributions of key partners in coordinating and delivering comprehensive asthma care and services and how their role is vital to delivery across their community asthma care system of asthma care based on the National Institutes of Health's 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group.

The key to winning the award is to demonstrate that your organization’s leadership has helped build a community asthma care system that—

Includes a robust environmental component;
Embodies the key drivers of program effectiveness—as described in the Change Package;
Promotes the integration of the 2020 Focused Updates to the Asthma Management Guidelines: A Report From the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group throughout the continuum of care; and
Achieves positive health and financial outcomes.

Your application must address the following three areas:

Content

This section of your application, worth 70 points in total, addresses three components of your comprehensive asthma care system: 1.a. Management and Operations, 1.b. Integrated Health Care Services, and 1.c. Indoor Environmental Determinants of Health (IEDOH) Solutions for Asthma. Below are the application guidelines and evaluation criteria for sections 1.a–1.c within the Comprehensive Asthma Management area of your application. As you present your asthma care system, please highlight your significant collaborations and your approach to reducing asthma disparities in the community you serve.

1.a. Management and Operations (10 points)

Application Guidelines	Evaluation Criteria
Describe your organization: What kind of organization are you—health care, public health, community-based, clinical provider, etc.? What is the history of your asthma care initiative— how did leadership for the mission arise? What asthma care needs did you recognize in your target population? How did you organize to address those needs? How has asthma care changed over time and why? Describe with as much detail as you can the demographics and prevalence of asthma in the population you serve. For example, include the age, common ethnicities, languages, income levels, housing status, and asthma burden in the population you serve (e.g., _____% asthma prevalence; _____% of asthma population with not well to poorly controlled asthma)	The applicant identifies the program’s mission, vision, history, leadership, and objectives. The applicant demonstrates strong community ties, partnerships and community engagement strategies specific, to the community's asthma disparities and needs. The applicant serves a population in significant need (for example, high asthma prevalence, significant asthma disparities, etc.) and targets care to address out of control asthma. The applicant continually assesses its service and delivery based on the community’s needs.

Application Guidelines

Evaluation Criteria

Describe your organization: What kind of organization are you—health care, public health, community-based, clinical provider, etc.?
What is the history of your asthma care initiative— how did leadership for the mission arise?
What asthma care needs did you recognize in your target population? How did you organize to address those needs? How has asthma care changed over time and why?
Describe with as much detail as you can the demographics and prevalence of asthma in the population you serve. For example, include the age, common ethnicities, languages, income levels, housing status, and asthma burden in the population you serve (e.g., _____% asthma prevalence; _____% of asthma population with not well to poorly controlled asthma)

The applicant identifies the program’s mission, vision, history, leadership, and objectives.
The applicant demonstrates strong community ties, partnerships and community engagement strategies specific, to the community's asthma disparities and needs.
The applicant serves a population in significant need (for example, high asthma prevalence, significant asthma disparities, etc.) and targets care to address out of control asthma.
The applicant continually assesses its service and delivery based on the community’s needs.

1.b. Integrated Health Care (20 points)

Application Guidelines	Evaluation Criteria
Please describe your community’s integrated asthma care system; specifically, demonstrate your leadership in coordinating delivery of comprehensive asthma care and identify your partners’ roles. Explain how you and partners deliver care that is aligned with the NIH NAEPP 2020 Focused Updates to the Asthma Management Guidelines. Describe how you support providers at all points of care to deliver Guidelines-based care that prioritizes indoor environmental interventions for people with asthma who need them. Describe how clinical practice incorporates the Guidelines; specifically, how your care system identifies, prioritizes, and coordinates services to address the clinical, social, and indoor environmental determinants of health (IEDOH) for people with asthma. Be clear about asthma services: what is available, for whom, based on what criteria, who can order services, who delivers them, where, and how are expanded services for asthma care financed? Describe with detail the percentages of your asthma population with access to solutions to address their IEDOH (e.g., ___% of asthma patients with poorly controlled asthma) have access to case management and up to eight in-home asthma education sessions with environmental counseling, supplies, and access to structural interventions with referrals to housing and energy services). Describe strategies your asthma care system, including partners, uses to expand access to asthma care in the community and in school and home environments to reduce asthma disparities (e.g., care coordination to address IEDOH, such as referrals for integrated pest management or weatherization services to help control moisture, reduce pest intrusion, and improve thermal comfort and control indoors). Describe tools, such as asthma registries, shared electronic records, or cross-references housing inspection and asthma emergency care data, for example, that help your community asthma care system to support timely communication and coordination of care.	Applicant shows leadership for integrating asthma care services to align with the NIH NAEPP 2020 Focused Updates to the Asthma Management Guidelines. Applicant describes the system for segmenting care—including risk-stratified and tailored therapy, medication, and community-based and in-home environmental intervention services—making clear which providers or partners provide asthma education at all points of care to promote self-management and the use of asthma action plans. Applicant addresses asthma disparities, including addressing IEDOH in asthma. Applicant demonstrates that mechanisms exist to support comprehensive community asthma care through the collection, coordination, management, and communication of data across the asthma care team, including data related to risk stratification, care history and treatment plans, assessment of indoor exposures, referrals and services, health care utilization, and asthma health outcomes.

Application Guidelines

Evaluation Criteria

Please describe your community’s integrated asthma care system; specifically, demonstrate your leadership in coordinating delivery of comprehensive asthma care and identify your partners’ roles.
Explain how you and partners deliver care that is aligned with the NIH NAEPP 2020 Focused Updates to the Asthma Management Guidelines. Describe how you support providers at all points of care to deliver Guidelines-based care that prioritizes indoor environmental interventions for people with asthma who need them.
Describe how clinical practice incorporates the Guidelines; specifically, how your care system identifies, prioritizes, and coordinates services to address the clinical, social, and indoor environmental determinants of health (IEDOH) for people with asthma. Be clear about asthma services: what is available, for whom, based on what criteria, who can order services, who delivers them, where, and how are expanded services for asthma care financed?
Describe with detail the percentages of your asthma population with access to solutions to address their IEDOH (e.g., ___% of asthma patients with poorly controlled asthma) have access to case management and up to eight in-home asthma education sessions with environmental counseling, supplies, and access to structural interventions with referrals to housing and energy services).
Describe strategies your asthma care system, including partners, uses to expand access to asthma care in the community and in school and home environments to reduce asthma disparities (e.g., care coordination to address IEDOH, such as referrals for integrated pest management or weatherization services to help control moisture, reduce pest intrusion, and improve thermal comfort and control indoors).
Describe tools, such as asthma registries, shared electronic records, or cross-references housing inspection and asthma emergency care data, for example, that help your community asthma care system to support timely communication and coordination of care.

Applicant shows leadership for integrating asthma care services to align with the NIH NAEPP 2020 Focused Updates to the Asthma Management Guidelines.
Applicant describes the system for segmenting care—including risk-stratified and tailored therapy, medication, and community-based and in-home environmental intervention services—making clear which providers or partners provide asthma education at all points of care to promote self-management and the use of asthma action plans.
Applicant addresses asthma disparities, including addressing IEDOH in asthma.
Applicant demonstrates that mechanisms exist to support comprehensive community asthma care through the collection, coordination, management, and communication of data across the asthma care team, including data related to risk stratification, care history and treatment plans, assessment of indoor exposures, referrals and services, health care utilization, and asthma health outcomes.

1.c. Indoor Environmental Determinants of Health (IEDOH) Solutions for Asthma (40 points)

Application Guidelines	Evaluation Criteria
Describe your environmental asthma care system and how it addresses indoor environmental determinants of health (IEDOH) in asthma, including exposures to environmental asthma triggers that may originate outdoors or indoors (but for most people, most exposures occur indoors). Describe with as much detail as you can how you prioritize solutions for indoor environments across your asthma care system. Describe the range of environmental education, counseling, supports, supplies, and interventions ranging from equipment to environmental modifications available to asthma patients at different risk levels. Examples may include in-clinic environmental counseling, in-clinic or home-based asthma education, telephone or social media outreach about environmental asthma triggers, in-home environmental assessment and remediation, provision of equipment or supplies, or home modifications (e.g., replacing leaky cookstoves or furnaces, integrated pest management services, installing air conditioners and air filters) to address indoor environmental exposures. Describe how you support providers across the care continuum in environmental asthma management (e.g., training, clinical care and decision support tools, quality review, financial support and partnerships) Describe with detail who delivers what kind of environmental asthma care solutions to which asthma patients (e.g., ___% of asthma patients [those diagnosed with poorly controlled asthma] receive in-home environmental assessment and referrals for remediation). Describe the frequency and duration of any environmental asthma care (e.g., up to six 1.5-hour visits per year conducted by a community health worker who can refer homes to environmental sanitarians for remediation). Explain how risk of environmental exposures in asthma is assessed, what referrals are available for environmental interventions, and how information is communicated across the care team, particularly between any in-home and in-clinic providers and community-based services. If your asthma care system provides tools and materials to patients to help them manage environmental asthma triggers, describe the supports, any supplies, and who is eligible to receive them. Describe your organization’s role in advancing community solutions to address the IEDOH in asthma, pointing out any innovative approaches. Discuss notable successes you can demonstrate that have resulted from the environmental focus on housing- and school-based exposures in your community’s comprehensive asthma care system.	Applicant demonstrates that environmental asthma management is a priority throughout the continuum of care by describing multifaceted interventions for the IEDOH in asthma that are available in multiple settings (e.g., clinic, hospital, school, community, home), tailored based on risk, and supported with training for providers and tools and materials for patients. Applicant demonstrates how its priority populations with asthma are identified and classified, what environmental interventions are available for which populations and how, when, where, and by whom indoor environmental interventions are delivered, including with what financial support and any certification or training required. Applicant makes clear how outcomes from environmental interventions are tracked and shared across the care team, including collaboration between the clinical and community components of environmental asthma care.

Application Guidelines

Evaluation Criteria

Describe your environmental asthma care system and how it addresses indoor environmental determinants of health (IEDOH) in asthma, including exposures to environmental asthma triggers that may originate outdoors or indoors (but for most people, most exposures occur indoors). Describe with as much detail as you can how you prioritize solutions for indoor environments across your asthma care system.
Describe the range of environmental education, counseling, supports, supplies, and interventions ranging from equipment to environmental modifications available to asthma patients at different risk levels. Examples may include in-clinic environmental counseling, in-clinic or home-based asthma education, telephone or social media outreach about environmental asthma triggers, in-home environmental assessment and remediation, provision of equipment or supplies, or home modifications (e.g., replacing leaky cookstoves or furnaces, integrated pest management services, installing air conditioners and air filters) to address indoor environmental exposures.
Describe how you support providers across the care continuum in environmental asthma management (e.g., training, clinical care and decision support tools, quality review, financial support and partnerships)
Describe with detail who delivers what kind of environmental asthma care solutions to which asthma patients (e.g., ___% of asthma patients [those diagnosed with poorly controlled asthma] receive in-home environmental assessment and referrals for remediation). Describe the frequency and duration of any environmental asthma care (e.g., up to six 1.5-hour visits per year conducted by a community health worker who can refer homes to environmental sanitarians for remediation).
Explain how risk of environmental exposures in asthma is assessed, what referrals are available for environmental interventions, and how information is communicated across the care team, particularly between any in-home and in-clinic providers and community-based services.
If your asthma care system provides tools and materials to patients to help them manage environmental asthma triggers, describe the supports, any supplies, and who is eligible to receive them.
Describe your organization’s role in advancing community solutions to address the IEDOH in asthma, pointing out any innovative approaches.
Discuss notable successes you can demonstrate that have resulted from the environmental focus on housing- and school-based exposures in your community’s comprehensive asthma care system.

Applicant demonstrates that environmental asthma management is a priority throughout the continuum of care by describing multifaceted interventions for the IEDOH in asthma that are available in multiple settings (e.g., clinic, hospital, school, community, home), tailored based on risk, and supported with training for providers and tools and materials for patients.
Applicant demonstrates how its priority populations with asthma are identified and classified, what environmental interventions are available for which populations and how, when, where, and by whom indoor environmental interventions are delivered, including with what financial support and any certification or training required.
Applicant makes clear how outcomes from environmental interventions are tracked and shared across the care team, including collaboration between the clinical and community components of environmental asthma care.

Content

This section of the application, worth 15 points in total, addresses how you evaluate asthma care outcomes and results. Applicants with only qualitative data, such as anecdotal evidence of results, will receive partial credit.

Area 2: Getting Results—Evaluation (15 points)

Application Guidelines	Evaluation Criteria
Discuss the measures your asthma care system tracks, including process measures, outcome measures, and costs. Describe how you and your partners follow asthma patients (e.g., in a registry) to collect and analyze information on diagnoses, treatments, referrals, interventions, health care utilization, quality of life, and cost of care outcomes, for example. If you have information specific to the effectiveness of interventions to address the indoor environmental determinants of health (IEDOH) in asthma, be sure to include this information. Describe in detail any results you attribute to your environmental asthma management activities. Discuss how you use outcomes data inside your organization and externally. Describe results in addressing your community’s asthma disparities. Describe your asthma care system’s approach to tracking systemwide costs and savings and any return on investment or increased health care value attributable to comprehensive asthma care.	Applicant demonstrates it tracks measures to assess quality of care, such as primary and specialty visit rates, timeliness of referrals, percentage of child patients evaluated for asthma control, access to environmental modifications, rates of patients and caregivers educated on environmental triggers and avoidance, and appropriate medication use. Applicant demonstrates that it tracks outcome measures, such as asthma urgent care utilization and asthma symptom-free days. Applicant demonstrates a system to capture data and evaluate results continuously to drive improvement over time. Applicant has cost data and some return on investment, cost-effectiveness, or other health care value analysis for its asthma care system. Applicant can demonstrate improved health outcomes against baseline. Applicant can demonstrate improved process and/or health outcomes attributable to management of the IEDOH in asthma care.

Application Guidelines

Evaluation Criteria

Discuss the measures your asthma care system tracks, including process measures, outcome measures, and costs.
Describe how you and your partners follow asthma patients (e.g., in a registry) to collect and analyze information on diagnoses, treatments, referrals, interventions, health care utilization, quality of life, and cost of care outcomes, for example.
If you have information specific to the effectiveness of interventions to address the indoor environmental determinants of health (IEDOH) in asthma, be sure to include this information.
Describe in detail any results you attribute to your environmental asthma management activities.
Discuss how you use outcomes data inside your organization and externally.
Describe results in addressing your community’s asthma disparities.
Describe your asthma care system’s approach to tracking systemwide costs and savings and any return on investment or increased health care value attributable to comprehensive asthma care.

Applicant demonstrates it tracks measures to assess quality of care, such as primary and specialty visit rates, timeliness of referrals, percentage of child patients evaluated for asthma control, access to environmental modifications, rates of patients and caregivers educated on environmental triggers and avoidance, and appropriate medication use.
Applicant demonstrates that it tracks outcome measures, such as asthma urgent care utilization and asthma symptom-free days.
Applicant demonstrates a system to capture data and evaluate results continuously to drive improvement over time.
Applicant has cost data and some return on investment, cost-effectiveness, or other health care value analysis for its asthma care system.
Applicant can demonstrate improved health outcomes against baseline.
Applicant can demonstrate improved process and/or health outcomes attributable to management of the IEDOH in asthma care.

Content

This section of the application, worth 15 points, addresses the components of environmental asthma care that receive health care reimbursement or, if coverage is not yet available, addresses the effort underway to establish coverage to sustain environmental asthma care.

Area 3. Sustainability (15 points)

Application Guidelines	Evaluation Criteria
Describe current and long-term funding, revenues, and other financing arrangements to sustain your system’s ability to deliver comprehensive asthma care that includes solutions for the indoor environmental determinants of health (IEDOH) in asthma. Describe how you finance any environmental asthma care, which components you can be reimbursed for currently, and strategies to expand reimbursement for solutions for the IEDOH in your community’s asthma burden. If applicable, describe payment and delivery models (e.g., Medicaid reimbursement, population-based payments, fee-based payments, accountable community organization partnerships) in place to support comprehensive asthma care services in your community. Describe how your asthma care system (i.e., you and your partners) track program-wide costs, savings, and return on investment and how you use such data to attract funders, supporters, and financial sustainability. Describe your efforts to expand funding for in-home environmental services and modifications to address the IEDOH in asthma for people at risk of poor health outcomes due to environmental exposures.	Applicant demonstrates a sustainability strategy for environmental asthma education and interventions. Applicant and its partners analyze return on investments in their asthma care system, including environmental components, and use information to advocate for expanded funding and population-health approaches that address the IEDOH in asthma. Applicant and partners demonstrate cost savings or positive returns.

Application Guidelines

Evaluation Criteria

Describe current and long-term funding, revenues, and other financing arrangements to sustain your system’s ability to deliver comprehensive asthma care that includes solutions for the indoor environmental determinants of health (IEDOH) in asthma.
Describe how you finance any environmental asthma care, which components you can be reimbursed for currently, and strategies to expand reimbursement for solutions for the IEDOH in your community’s asthma burden.
If applicable, describe payment and delivery models (e.g., Medicaid reimbursement, population-based payments, fee-based payments, accountable community organization partnerships) in place to support comprehensive asthma care services in your community.
Describe how your asthma care system (i.e., you and your partners) track program-wide costs, savings, and return on investment and how you use such data to attract funders, supporters, and financial sustainability.
Describe your efforts to expand funding for in-home environmental services and modifications to address the IEDOH in asthma for people at risk of poor health outcomes due to environmental exposures.

Applicant demonstrates a sustainability strategy for environmental asthma education and interventions.
Applicant and its partners analyze return on investments in their asthma care system, including environmental components, and use information to advocate for expanded funding and population-health approaches that address the IEDOH in asthma.
Applicant and partners demonstrate cost savings or positive returns.

Content

Our priorities when evaluating applications for award are described on each tab: Comprehensive Asthma Management, Getting Results—Evaluation, and Sustainability. Your responses across the three application areas will be assessed against the described criteria, which are designed to identify national leaders. Be sure to highlight features that are innovative and distinguish your community’s approach.

Throughout your application, we encourage you to highlight key roles played by your partners and collaborators to complete a community system of care. For example, some partners might provide school- or home-based interventions or social services. Please note that the applications distinguish between your organization’s activities and activities critical to the delivery of quality asthma care that may be performed by your collaborators using the following terms:

The applicant and organization (“you”).
The organizations you work with to provide asthma services in your community (your “partners”).
You and the collaboration of partners in an asthma care system in your community setting (your “program and your partners”).

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Questions about the application process? Review application FAQs or send an email to EPALeadershipAwards@AsthmaCommunityNetwork.org.

Application Guidelines & Evaluation Criteria

Area 1: Comprehensive Asthma Management

1.a. Management and Operations (10 points)

1.b. Integrated Health Care (20 points)

1.c. Indoor Environmental Determinants of Health (IEDOH) Solutions for Asthma (40 points)

Area 2: Getting Results—Evaluation

Area 2: Getting Results—Evaluation (15 points)

Area 3: Sustainability

Area 3. Sustainability (15 points)

Application Guidelines & Evaluation Criteria

Area 1: Comprehensive Asthma Management

Area 2: Getting Results—Evaluation

Area 3: Sustainability

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