Identifying and Engaging Patients


I think CHAMPS did open the idea of okay, everyone can be a team member in patient care; it’s not just the doctor. The nurse plays a role, even people who work the front desk and reception area. Everyone works as a team to generate the goal that we want. – Physician

Practices implementing the CHAMPS intervention need processes for identifying and engaging ideal patient candidates.

Identifying Patients

The patients most likely to benefit from the CHAMPS intervention are children with moderate-to-severe and poorly controlled asthma, as defined by the National Heart, Lung, and Blood Institute's Guidelines for the Diagnosis and Management of Asthma. We strongly recommend clinicians implement guideline-based care into their practice. Learn more about identifying patients for continuous care in this brief CHAMPS e-Learning video. Learn more about implementing guidelines-based care in this brief CHAMPS e-Learning video.


Patients can be identified and referred to CHAMPS as part of their normal care visits, but consider using more proactive approaches to identify patients for the program. For example, identify candidates by reviewing pharmacy records or patient diagnostic registries. Also consider advertising the program within your practice and throughout your community (e.g., posters, flyers, local media).


Use the Asthma Symptoms & Utilization (ASU) questionnaire to quickly identify patients who are likely to benefit from CHAMPS. Please note, the ASU questionnaire is not intended to diagnose asthma control or severity - it is only used as a screening tool for CHAMPS.


The ASU focuses on the patient's:

  • Asthma Symptoms in the previous 4 weeks
  • Asthma-related healthcare usage(e.g., urgent care visits for asthma, asthma-related hospitalizations) in the last year
  • Medication use for asthma

Engaging Patients

The CHAMPS intervention is designed as year-long program with multiple visits and points of contact between the health care team and the patient. Then intervention is most successful with families who are committed to attending scheduled visits and implementing the treatment and behavioral changes recommended by the health care team. While it is impossible to guarantee patient commitment and engagement to the intervention, several factors can help lead to engaged families:


  • Skilled Asthma Counselor - patient engagement and retention is strongly influenced by the ability of the asthma counselor to build trusting relationships with families. To learn more about the qualities of a strong asthma counselor refer to the Background and Training section of the Manual here.


  • Engagement from Providers - the entire healthcare team needs to support the CHAMPS intervention; patients trust their healthcare providers—an enthusiastic recommendation to participate in CHAMPS will go a long way to boosting patient engagement; learn more about provider engagement in the Essential Elements of Success section of the Manual.


  • Emphasis on Personalized Care - the CHAMPS intervention provides a family-centered, patient-tailored approach designed to meet the specific needs of each patient and family; the CHAMPS intervention is personalized to the unique asthma risk factors, environmental exposures, and allergic sensitivities of each child; families are more likely to be engaged if they know the intervention is unique to them; emphasize the personalized aspect of the intervention at every opportunity; learn more about the personalized intervention in the Tailoring the Intervention section of the Manual.
  • Patient Incentives - even with the promise of improved health for their child, keeping families engaged for a year-long program can be challenging. Sometimes additional incentives can be used to help motivate families to stay involved. Incentives can include giving the families the home environment remediation supplies (e.g., HEPA filters, HEPA vaccums). Previous CHAMPS program sites found that giving the families modest gift cards for local merchants was also a way to keep them engaged, at a minimal cost to the practice. 
  • Emphasis on Evidence-Based Research - the CHAMPS intervention is based on over 20 years of evidence-based research in asthma; the components of the intervention have been replicated in controlled clinical trials and in “real-world” primary care practices around the country; emphasize the strong research foundation of CHAMPS with families.


Next: Learn about Conducting Patient Assessments.