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.

Conduct Needs-Based Planning--Seek Input from the Community

Community ownership and integration has been built into WIN's program design from the start. When they received the MCAN grant, the researchers who initiated WIN convened a network of community stakeholders committed to filling gaps in the local system of asthma care. The research team and representatives from four community-based organizations--Alianza Dominicana, Inc., Northern Manhattan Improvement Corporation, Fort George Community Enrichment Center and Community League of the Heights--joined together to design WIN. They applied the principles of community-based participatory research and spent the first nine months setting program strategy, recruiting and training staff from the community, developing asthma care guidelines and protocols, creating evaluation tools and forming the WIN Leadership Task Force. The Task Force, which includes stakeholders from the community, Columbia University and the hospital, oversees and supports WIN programming.

Ensure Mission-Program Alignment

To ensure it stays focused on asthma disparities, WIN works hard to find and treat at-risk children by conducting screening for uncontrolled asthma in daycare facilities, schools, clinics and other community organizations. In addition, all children admitted to the Morgan Stanley Children's Hospital of New York with a diagnosis of asthma are automatically referred to WIN. Through its broad network of collaborators, WIN is able to assess a large pediatric population. Families of children who meet the risk criteria are offered WIN's intensive year-long care coordination service. 

WIN's target population is multi-lingual, culturally diverse, has low levels of health literacy and high levels of poverty and faces multiple obstacles that often prevent effective asthma care. To make it easy for families to support effective asthma care for their children, WIN's care model uses bilingual community health workers (CHWs) located in organizations across the community. The CHWs serve as the single point of contact for families to facilitate culturally-appropriate and comprehensive asthma education, home environmental assessments, support for setting individualized asthma control goals, referrals for clinical and social services and ongoing support. The CHWs, who are linked to the hospital and the community, facilitate communication with clinicians, provide broad-spectrum support to families and strengthen ties between the health care system and the community.

Let Data Guide the Program Planning, Design and Implementation

SUHI and SCH targeted their work in the Westside area, because they had strong data indicating the community's considerable need for improved asthma care. In 2003, SUHI worked with community organizations in Chicago to design and conduct the largest door-to-door health survey in the city's history. Findings indicated high rates of poorly controlled asthma in North Lawndale, a neighborhood in the heart of Chicago's Westside where Sinai Health System also is located. The survey revealed that 23% of children in the area had a diagnosis or symptoms of asthma; 80% of children with an asthma diagnosis were not receiving appropriate medications; and nearly half were exposed to tobacco smoke on a daily basis. In addition, the pediatric asthma hospitalization rate in North Lawndale from 2004 to 2006 was 150% higher than the rate in the rest of Chicago.  The data influenced the design of asthma interventions, particularly the selection of the CHW-led home visit model. This model brings culturally sensitive care to the community to ensure a strong connection to the health care system and provide interventions in the environments where children spend the majority of their time. 

Start Small to Get Big

Beginning in 2000, SCH and SUHI began partnering on a pediatric asthma initiative to reduce the impact of asthma through case management and one-on-one asthma education delivered in a clinic and by telephone. The next stage of program development focused on reducing asthma-related morbidity and improving quality of life (QoL) by utilizing CHWs delivery of case-specific asthma education through home visits. The third iteration of the program incorporated SUHI/SCH's successful CHW-led home-visit model into a larger, statewide initiative led by the Illinois Department of Public Health to improve pediatric asthma outcomes.

SUHI's and SCH's research conducted on the three prior initiatives yielded significant reductions in asthma-related health care utilization. This culminated in the development of the most comprehensive initiative to date: the HHHC. The HHHC exclusively focuses on children with poorly controlled asthma living in poor communities on the Westside. The program's objective is to significantly impact asthma-related measures of morbidity, urgent health care utilization and QoL by decreasing asthma triggers in the home environment, improving asthma care knowledge among primary caregivers and improving caregivers' confidence in their ability to manage asthma. To achieve these goals, CHWs provide asthma education during six home visits over the course of a year. Visits focus on providing tailored education to caregivers and children on medical management and addressing the disproportionate presence of asthma triggers in the home. Having CHWs visit participants' homes means that families do not have to arrange for transportation as visits can be scheduled to accommodate families. The CHWs can serve as advocates and liaisons between the families and the broad network of partners that SCH and SUHI have assembled to support the HHHC. The CHWs also record case information in a shared database for partners to access and initiate extensive telephone and email communication to discuss cases, asthma management education, home environmental exposures and controls, needed social support and assistance families need to navigate the health care system.

Conduct Needs-Based Planning: Seek Input from the Community

CAB helps to ensures that HHHC receives vital insight into its community. The CAB guides the asthma outreach and home intervention process and helps the program reach as many children as possible by educating the community about the program and how to access it. CAB members include parents and caregivers of children with asthma, leaders of community-based organizations, representatives from faith-based groups, business owners and other stakeholders. The CAB engages the community, guides the program's design and helps to foster sustained asthma care improvements.

Let the Data Guide Program Planning, Design and Implementation

Initially, NHP's ADMP focused on characterizing the asthma population in Massachusetts by developing a registry to house medical and pharmacy data that will help NHP assess clinics' effectiveness in controlling their members' asthma and allow NHP to identify potential areas for improvement. In response to its data collection efforts, the program has expanded and today, NHP delivers a tiered disease management approach. The interventions are based on risk stratification and include generalized educational mailings, personalized case management and telephonic outreach; intensive home visits; and close coordination between home visitors, asthma care managers and providers. Currently, NHP is expanding to its ADMP by helping 10 community health centers that serve some of the plan's most at-risk members with asthma to adopt routine spirometry by providing equipment, training staff to perform tests and teaching providers how to interpret results. This intervention will benefit NHP members with asthma and all health center clients in these underserved, diverse communities, who are often the last to benefit from advances in medical technology.

Ensure Mission-Program Alignment

NHP was one of the nation's first health plans created specifically to address the health care needs of the underserved. It grew from a few thousand members in the late 1980s to more than 200,000 members today. Asthma is the number one chronic disease among NHP's members, affecting over 10% of its members, and the prevalence of asthma is higher in Massachusetts than in most states. It is highest among minority populations, including African Americans and Hispanics and low-income residents. To help address the disproportionate impact of asthma on low-income and minority communities, who are frequently exposed to high levels of housing-based asthma triggers and often unable to address structural impediments to environmental trigger controls, NHP developed its EAHVP in 2005. The EAVHP targets pediatric and adult allergic asthma members who, despite using appropriate controller medications, are experiencing uncontrolled asthma due to significant environmental exposures. The EAHVP provides home assessments and materials to help control environmental triggers and connects members to counseling and institutional support, such as public housing management and tenants rights programs, to help reduce environmental exposures.

Build Evaluation in from the Start--Establish a Process to Collect the Data You Need

NHP's registry is a powerful tool to drive identification of patients with poor asthma control, target provider education to improve clinical care and ensure utilization of aspects of the ADMP to those members most in need. NHP runs quarterly reports from the registry to identify members who may benefit from the ADMP. ADMP also can identify members through screenings, in-patient or ED utilization, high recent use of rescue medications and direct referrals. NHP then uses the registry reports to improve clinical care by providing site-specific information on in-patient and pharmacy utilization over the previous 12 months.  Most sites also receive bi-weekly trigger reports, which identifies patients with current poor asthma control. NHP sends about 1,200 letters with individualized treatment recommendations to primary care providers each month based on their patients' presence on the trigger report. These members whose names appear on the trigger reports, receive educational mailings. The mailings include low-literacy information that defines good asthma control and describes the steps members can take to improve their asthma control, and a multi-lingual DVD providing video instruction on proper use of asthma delivery devices.

Ensure Mission-Program Alignment

CAI seeks to improve pediatric asthma outcomes for the most severely affected children in Boston. Asthma is the leading cause of hospitalization at Children's and the majority of Children's asthma patients come from Boston's poorest and most ethnically diverse neighborhoods. To ensure CAI reaches its target population, it enrolls children who have been hospitalized or admitted to the ED for asthma in a year-long case management program and gives priority enrollment to children who have had admissions or multiple ED visits.

Let the Data Guide the Program Planning, Design and Implementation

As soon as CAI began assessing patients who frequented Children's for emergency asthma care, it became obvious that social and environmental issues were significant contributors to asthma severity within the program's target population. The neighborhoods clients are drawn from have a high percentage of older rental housing, significant mold, dust and pest allergen issues and high rates of poverty, unemployment, language barriers and low health literacy. In response, CAI designed a program that matches high-need children and their families with culturally appropriate case management that strengthens the connection to a medical home, helps families obtain insurance and affordable medications and facilitates access to community-based asthma care resources, such as home visits and housing advocacy assistance.