Area 1: Comprehensive Asthma Management

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. Tailored Environmental Services. Click on the arrows at the left in the headings below to reveal 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 (20 points)

Application Guidelines Evaluation Criteria
  • Describe your organization: What kind of organization are you—a health care, public health, community-based, clinical or other provider? A different kind of organization?
  • 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 the 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 provides evidence that leaders have come together in this community to promote a comprehensive asthma care system to reach the people most in need of care.
  • The applicant demonstrates strong community ties and an asthma care operation that reflects the community it serves.
  • The applicant serves a population in significant need (e.g., high asthma prevalence, significant asthma disparities) and targets care to address out-of-control asthma.
  • The applicant has taken specific steps to increase asthma care accessibility.
  • The applicant continually assesses its service and delivery based on the community’s needs.

1.b. Integrated Health Care Services (20 points)

Application Guidelines Evaluation Criteria
  • 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 EPR-3 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 percentage of your target population that receives different services (e.g., ___% of asthma patients [those with very poorly controlled asthma] receive case management and six to eight 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 NIH EPR-3 Guidelines.
  • The applicant describes its and its partners’ process to deliver targeted, risk-stratified and tailored therapy, medication and services; provide asthma education at all points of care; promote self-management; and 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 strong community ties, partnerships and community engagement strategies specific to its community’s asthma disparities and needs.
  • The applicant demonstrates that mechanisms exist to support comprehensive community asthma care through the centralized collection, coordination, management and utilization of data related to patient enrollment, diagnosis, risk stratification, care history and treatment plans, referrals, utilization, and disease outcomes across the asthma care team.

1.c. Tailored Environmental Services (30 points)

Application Guidelines Evaluation Criteria
  • Describe the environmental components of your comprehensive asthma care system that address indoor and outdoor environmental triggers and how you ensure that environmental care and services are integrated across the care continuum.
  • Describe the range of environmental care, services 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, telephone outreach about environmental asthma triggers, in-home environmental assessment and remediation, provision of equipment or supplies, or other strategies.
  • Describe how you support providers across the care continuum in environmental asthma management (e.g., training, clinical care and decision support tools, quality review).
  • 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). Please clarify who receives services, where, how, delivered by whom, and what percentage of your target population receives what services, based on what criteria.
  • Explain how environmental asthma care needs and services are determined, reported and referred and how information is communicated between members of the care team, particularly between the in-home and in-clinic care teams.
  • If your asthma care system provides tools and materials to patients to help them manage environmental asthma triggers, describe them and who receives them.
  • Describe your organization’s role in advancing community-wide solutions to address the environmental factors in asthma pointing out any innovative approaches.
  • Discuss notable successes you can demonstrate that have resulted from the environmental component 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 environmental interventions that are available in multiple settings (e.g., clinic, hospital, school, community, home) and tailored based on patient risk. Within these interventions, asthma care providers are supported through regular training, decision support, and tools and materials to assist 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, and 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.


Links to other areas within the National Environmental Leadership Award in Asthma Management application appear below: