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. Indoor Environmental Determinants of Health (IEDOH) Solutions for Asthma. 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 (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.

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 environmental determinants of health 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 environmental determinants of asthma (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).
  • 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 determinants of health, such as referrals for integrated pest management or weatherization services to help control moisture, reduce pests, and address thermal comfort indoors).
  • Describe tools, such as asthma registries and electronic records, 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 prioritizing and segmenting care—including risk-stratified and tailored therapy, medication, and community-based 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 demonstrates leadership addressing asthma disparities in the community, including addressing indoor environmental determinants of health (known as the IEDOH) in asthma.
  • Applicant demonstrates 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, referrals, 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)
  • 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 of 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.


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