Promote Institutional Change for Sustainability
As clinical and provider training programs took root within the Woodhull system, the asthma program began partnering with health care organizations and providers, community and faith-based organizations and community leaders to create the venues needed to deliver a single high standard of asthma care to the entire community. Woodhull received funding from the New York State Department of Health (NYDOH) Office of Minority Health to spearhead a coalition focused on racial disparities in asthma care. This led to the creation of the North Brooklyn Asthma Action Alliance (NBAAA), a community coalition to champion policy-level change in asthma management in schools; increased awareness of patient rights; and expansion of the PACE program to reach providers across the community. Because of the commitment of its members to health, environmental and social justice issues, the NBAAA has continued to meet on a voluntary basis even during periods when funding has lapsed.
Woodhull has carefully applied grant funding to promote institutional change, thereby minimizing the need for future grant funding to sustain improvements. For example, in the most recent five-year period, NYDOH funded Woodhull to expand its coalition to reduce the asthma burden statewide. This approach resulted in partnerships with local schools to institute policy-level changes to ensure "asthma friendly" school environments. It also led to the development of new policies regarding animals in the classrooms, the use of carpeting, enforcement of the bus idling law and the use of green cleaning products. Once established as policy, environmental management of asthma became part of the institutional culture in the school system and, therefore, the intervention continues even after the funding period. Similarly, a Centers for Disease Control and Prevention grant that funded the development of the computerized asthma registry to track patient care helped to prove the concept and value of a computerized disease registry. Now the registry system is part of the infrastructure of the program and the hospital has maintained it beyond the pilot funding period.
The Woodhull North Brooklyn Health Network (Woodhull) is the primary safety net hospital for North Brooklyn. Woodhull began its comprehensive asthma management program in 1998 to respond to high asthma rates in the community. The program's goal is to ensure that everyone seen at any of the 15 Network facilities receives the same high standard of asthma care resulting in improved self-management and improved health outcomes.
Woodhull developed the first asthma friendly school program in New York City when the hospital worked with local school principals and parent coordinators to develop a school environmental assessment checklist. The program later integrated EPA's Indoor Air Quality Tools For Schools guidance and, in partnership with EPA and Rutgers University, now delivers comprehensive education on environmental asthma triggers in schools and how to manage them. In addition, Woodhull designates one of their certified asthma educators as a schools liaison to promote coordination of care for children at school. The liaison rotates pediatric residents to the 15 public schools in the district to provide asthma education to parents and school staff and screen children for asthma. Woodhull also maintains an asthma-friendly environment in the hospital-run day care center and offers workshops to community day care centers on how to manage asthma and the triggers of asthma.
Let the Data Guide Program Planning, Design and Implementation
Woodhull developed its asthma program to address the high pediatric asthma rates and poor outcomes in North Brooklyn. Research showed that children in the area suffered disproportionately from exposure to asthma triggers. Also, the numbers of pediatric patients with recurrent emergency department (ED) visits and hospitalizations for asthma indicated a lack of adequate clinical care. Woodhull leaders selected an evidence-based approach--the Chronic Care Model--to tackle pediatric asthma. Their approach included improving the quality of care and strengthening connections between and among care providers and the at-risk community the program is designed to reach. Woodhull aimed to decrease ED visits and hospitalizations by 50% within five years. To achieve these goals, the program delivers asthma care in a clinic that serves all regardless of their ability to pay; trains providers to improve the quality of care across the network; collaborates with local schools to identify and educate children with asthma; delivers home visits and case management for the highest risk patients; provides enhanced asthma care in the ED; and works through wide-ranging community collaborations to provide social and environmental support to families in need.
Woodhull developed their comprehensive asthma clinic as part of it parent organization, the New York City Health and Hospitals Corporation, Chronic Care initiative. The asthma clinic helps to ensure that all children with an asthma diagnosis in the Woodhull Network receive treatment in accordance with the National Guidelines for the Diagnosis and Management of Asthma (EPR-3). The Woodhull asthma program also began training attending, community and ED doctors, residents and nurses on the EPR-3 and implemented a number of innovations to reinforce the delivery of EPR-3-based care. For example, Woodhull modified their electronic health record to make it impossible to close an asthma encounter without providing a medication prescription based on severity classification. Woodhull also implemented a program to educate patients before clinical visits to ensure they are prepared to ask questions that will elicit high quality and personalized care from providers.
STRONG COMMUNITY TIES--MAKE IT EASY TO ACCEPT SERVICES
Woodhull makes high-quality asthma care convenient for children with poorly controlled asthma. Early in the program's development, Woodhull renovated the ED with a state-of-the-art asthma treatment room and began training ED doctors on EPR-3-based asthma care. It also eliminated the traditionally long wait times for patients to begin emergency medication by adding social workers on site to help with paperwork while patients receive nebulizer treatments. Because many underserved pediatric asthma patients end up at the ED, these enhancements ensure they receive the best care possible even under suboptimal circumstances. Also, asthma program staff contact patients seen in the ED within a few days to schedule a follow-up appointment at the clinic.
INTEGRATED HEALTH CARE SERVICES--PROMOTE ROBUST PATIENT/PROVIDER INTERACTION
Patient People Reaching Empowerment Program (PREP) for Asthma cards present the EPR-3 for asthma care in lay terms to educate consumers about what constitutes a comprehensive, quality visit. This information empowers patients to take control of their own asthma care and form a relationship with their providers. For example, the pediatric PREP card, includes a question about medication availability at school, AAPs and peak flow meters to prompt families to discuss these aspects of care with providers and prompt providers to take action if the child is missing any of these elements of care.
Evaluate Program Implementation and Program Impact
Woodhull assesses its asthma program by surveying providers who receive education through the Physician and Nursing Asthma Care Education (PACE) program. PACE participants report they are now more likely to prescribe inhaled anti-inflammatory therapy, give patients written treatment plans, review instructions for new medications with patients and address patients' fears about using new medications. Woodhull also assesses whether the providers' asthma education is actually affecting the quality of care. This is done by tracking registry data on the percent of the population who have asthma diagnoses that have been classified for severity; and have received appropriate medications, asthma action plans (AAPs) and tobacco screenings. The registry also provides outcomes data on hospitalizations and ED visits. Woodhull's results are impressive. Comparing ED visits and hospitalizations for 322 pediatric patients in the six months prior to clinic participation to the rates in the six months after, showed a 67% reduction in hospitalizations and a 58% reduction in ED visits.