Area 1: Comprehensive Asthma Management

Describe your community’s integrated asthma care system; specifically demonstrate your leadership role in delivering and coordinating comprehensive asthma care and identify roles your partners fill.

Explain how you and / or your partners promote and deliver care that is consistent with the NIH NAEPP 2020 Focused Updates to the Asthma Management Guidelines. Make sure to describe how you support providers across the continuum of care to deliver Guidelines-based care.

Describe specifically how clinical practice incorporates the Guidelines, and how your system identifies, targets services to, and coordinates care for people with not well to very poorly controlled asthma. Be clear about asthma services:  what is available, for whom, who can order services, who delivers them, where and how, and how is the quality of care ensured?

Describe with as much detail as you can the percentages of your target population that receives different services (e.g., ___% of asthma patients (those with very poorly controlled asthma) receive case management and 6 – 8 in-home asthma education and environmental interventions per year).

Describe specific strategies you and your partners employ to increase accessibility of care and reduce asthma disparities (e.g., aggressive care coordination to ensure transportation, electricity, and a clean home environment for Medicaid children with very poorly controlled asthma).

Describe the systems, such as asthma registries and electronic records, that your system uses to support timely, effective communication and coordination of care.

The applicant demonstrates leadership for ensuring the integration and delivery of comprehensive asthma care services that reflect the NAEPP 2020 Focused Updates to the Asthma Management Guidelines.

The applicant describes its and its partners’ process to deliver targeted, risk-stratified, and tailored therapy, medication, and services; to provide asthma education at all points of care; to promote self-management; and to encourage the use of asthma action plans.

The applicant addresses health disparities in the community and explains how its leadership helps to tackle those disparities in an innovative and effective manner.

The applicant demonstrates that mechanisms exist to support comprehensive community asthma care through the collection, coordination, management and use of patient diagnosis, risk stratification, care history and treatment plans, referrals, health care utilization, and asthma health outcomes data throughout the asthma care team.

Describe the environmental components of your comprehensive asthma care system that address indoor and outdoor environmental determinants of health, such as exposures to indoor asthma triggers, and how you ensure that environmental care and services are considered at points across the care continuum.

Describe the range of environmental education, supports, and interventions that are available to asthma patients at different risk levels. Examples may include in-clinic environmental counseling, in-clinic, or home-based asthma education; telephonic outreach about environmental asthma triggers; in-home environmental assessment and remediation; provision of equipment or supplies; or other strategies to address environmental exposures that can determine asthma health outcomes.

Describe how you support providers across the care continuum in environmental asthma management (e.g., training, clinical care and decision support tools, quality review, etc.)

Describe with as much detail as you can who delivers what kind of environmental care and service to which asthma patients (e.g., _____% of asthma patients (the strata with very poorly controlled asthma) receive in-home environmental assessment and remediation), and the frequency and duration of environmental care (e.g., up to six, 1.5 hour visits per year conducted by a certified asthma educator and environmental sanitarian).

Explain how risk of environmental exposures in asthma care needs are determined and referred for service and support, where necessary for asthma control, and how information is communicated across the care team, particularly between the in-home and in-clinic teams.

If your asthma care system provides tools and materials to patients to help them manage environmental asthma triggers, describe the supports and who is eligible to receive them.

Describe your organization’s role in advancing community-wide solutions to address the indoor environmental determinants of health in asthma pointing out any innovative approaches.

Discuss notable successes you can demonstrate that have resulted from the environmental focus of your community’s comprehensive asthma care system.

The applicant demonstrates that environmental asthma management is a priority throughout the continuum of care by describing multi-faceted interventions for the indoor environmental determinants of health that are available in multiple settings (i.e., clinic, hospital, school, community, home), tailored based on patient risk, and supported through training and decision supports for asthma care providers and tools and materials for asthma patients and their families.

The applicant demonstrates how its population with poorly controlled to very poorly controlled asthma is identified, what environmental interventions are available for that population, how those interventions are delivered, when, where, and by whom.

The applicant makes clear how results and outcomes from environmental interventions are communicated across the care team, including how collaborations support the integration of medical and environmental asthma care.