Urban Health Plan (UHP) is a network of nine community health centers and nine school-based health centers located in the South Bronx, NY—the poorest congressional district in the country—and in Corona, Queens, NY. Located within UHP’s catchment area, in Hunts Point, Bronx, is the largest food distribution center in the country. As a result of the traffic and pollution generated by the trucks used to distribute food, Hunts Point has one of the highest asthma rates in New York City. Due to the incidence and prevalence of asthma in this area, and because many of UHP’s patients are unaware that they have asthma, early diagnosis is critical. By integrating asthma care into primary care, all patients are screened for asthma every 6 months, including those with no history of asthma. In 2009, 1,000 patients were screened and 22 percent were diagnosed with asthma.

Asthma Relief Street, UHP’s asthma management program, cares for more than 12,000 people with asthma using a multidisciplinary program that is fully integrated into its primary care practice. The primary care provider, health educator and medical assistant (MA) work closely with UHP’s allergists, pulmonologists, social service workers and the integrated pest management program, as well as with New York City Asthma Intervention and Relief (a.i.r. nyc), to provide integrated health care services.

UHP has created long-lasting relationships with community organizations and has partnered with local hospitals and the neighborhood’s shelters to provide support and asthma education to their constituencies. UHP works closely with the New York City Department of Health’s New York City Asthma Partnership, a citywide coalition that brings together more than 400 community-based organizations and individuals to make recommendations to improve citywide policies and systems that affect people with asthma. This partnership is coordinated by the New York City Asthma Initiative.

UHP has developed a unique workflow algorithm to help identify patients and optimize appropriate treatment and followup. Any patient who visits UHP for primary health care services, whether he or she is an asthma patient or not, meets with an MA who ask a series of questions about asthma and asthma risks, following UHP’s asthma template or asthma-screening template. This visit with the MA is followed by a visit with the primary care provider, who reviews the patient’s responses to the MA’s questions about signs and symptoms and the Asthma Control Test, focusing on medication use; reviews and updates the patient’s Asthma Action Plan as needed; and answers any patient questions. Following the visit with the provider, a health educator holds a counseling session with the patient and reviews five asthma lesson plans: (1) definition of asthma (2) the signs symptoms of exacerbations (3) recommendations on remediation in the home to address environmental triggers (4) differences between "controller" and "rescue" medications (5) and understanding of spirometry and exhaled nitric oxide. Health educators also address any concerns the patient might have about asthma management. This process is repeated during all visits.

UHP’s goal is to empower patients and families to better manage their illness, so patients are encouraged to set self-management goals with the asthma health educator. The five-lesson asthma curriculum, which was developed by UHP clinicians, is used to educate both patients and their families. Using a self-management tool box that includes placebo medications, spacers, peak flow meters, masks, and sample Asthma Action Plans (AAPs), the health educator provides hands-on demonstrations on how to use the metered dose inhalers, dry powdered inhalers and nebulizers. Through an arrangement with various vendors, nebulizer compressors and aerochambers are provided to patients who need this equipment for treatment at home. This allows the health educator to provide hands-on demonstrations on how to use the machine and to provide cleaning and storage instructions to patients.

As of December 2015—

• 89 percent of UHP’s patients have had a severity assessment.
• 99 percent of patients with a severity assessment of “persistent asthma” are treated with anti inflammatory medications.
• 50 percent of UHP’s patients have documented self-management goals.
• 56 percent of UHP’s patients receive the influenza vaccine each year.
• 3 percent of UHP’s patients had urgent care or emergency department visits in the previous 6 months and an average of 11 symptom-free days and 0.156 work/school days lost per month.