Health Care Provider

Children’s Hospital of Richmond at VCU’s You Can Control Asthma Now (UCAN) community asthma program helps children who live in the Richmond, Virginia, metropolitan area where both asthma and poverty rates are disproportionately high.  Established in 2015, UCAN has served more than 344 patients using a family-focused case-management approach. Families are typically enrolled following an uncontrolled asthma-related emergency room visit or hospitalization, but can also be referred by their primary care physician or self-refer.   UCAN patients are assigned a pulmonologist (lung doctor) who provides comprehensive asthma care, receive asthma education from a nurse, and are provided resources and support to address barriers to treatment following evaluation by a social worker.  They receive follow up communication via text and phone calls, and are referred as needed for a Healthy Homes assessment through the City of Richmond Health District. UCAN also collaborates with the Medical Legal Partnership Program to empower families to address environmental housing issues not properly addressed by landlords. UCAN has saved $691 per patient through decreased hospitalizations and emergency room visits – leading to an overall cost reduction of $163,958. 

Mobile Care Chicago is a not-for-profit organization that uses mobile medical clinics to assist children currently unable to access necessary specialty care for a chronic condition. For 19 years, Mobile Care Chicago has used partnerships with local schools to provide a convenient and trusted location for local children who have complex needs but whose parents may not have the time, transportation or work flexibility to access more distant brick-and-mortar clinics. Mobile Care Chicago currently operates two Asthma Vans for children with severe asthma and/or allergies, a Dental Van for children who need oral surgery, and a Portable Dental Clinic that can be set up inside of schools to make referrals to the Dental Van. In total, Mobile Care Chicago’s mobile clinics serve roughly 8,000 patients per year, seeing the vast majority multiple times per year.

Research suggests that in lower income Chicago neighborhoods, such as Humboldt Park and the South Shore, more than 25% of children have asthma. Chicago has the second-most asthma fatalities of all cities in the United States, according to the Asthma and Allergy Foundation of America. Most fatalities happen in Cook County neighborhoods where asthma is not well-controlled because of lack of available medical care. The Illinois Department of Public Health estimates that 76.5% of children with asthma in Illinois qualify as “not well-controlled, with the vast majority of cases reported in low-income areas.” 

Asthma Vans go directly into lower income communities where specialty care access is an issue. The Asthma Vans then provide ongoing medical support to children with asthma, with a focus on adopting the medical care of its patients from their first appointment until the child turns 19 or graduates from high school. The average patient currently stays with their Asthma Van for more than 7 years. Mobile Care Chicago has screened more than 125,000 children for asthma in its 19-year history and provided comprehensive asthma care to more than 12,000 vulnerable children through more than 44,000 patient visits.

In recent years, Mobile Care Chicago has focused on high-intensity interventions for children with the most severe asthma/allergy conditions, including some children who had been cycling through local emergency departments more than 50 times per year. Through a team of nurse practitioners, allergists and community health workers, the Asthma Vans provide a series of home environment assessments, direct medical treatment and therapy, telemedicine and telehealth support for families, on-going education, and a 24-hour hotline staffed by the nurse practitioner team. The 3-year pilot of this high-intensity asthma control method reduced pediatric asthma emergency room visit rates by 84% in one Chicago hospital that previously had one of the highest rates of asthma admittances.

Patients assisted through the Asthma Vans have seen a more than a 50% decrease in school absenteeism and emergency department visits. Last year, only 6% of Asthma Van patients used an emergency room, versus 55% in the year prior to enrollment. The reduction in hospitalization rate alone (19% to 2% for Mobile Care Chicago patients) has saved the local health care system at least $156 million during the past 13 years. In addition, the Illinois Department of Public Health estimates that uncontrolled asthma costs the state of Illinois $15,155 per individual. By contrast, Mobile Care Chicago spent an average of $836 on each patient in the last fiscal year. This represents a 94% savings for each patient whose asthma is controlled.

Mobile Care Chicago’s early intervention screenings and mobile medical care delivery in hard-to-access and low-income communities has encouraged action and change in the surrounding Chicago communities, bringing asthma relief for thousands of children and peace of mind for parents.

The Pediatric Asthma and Allergy Clinic (PAAC) at the Children’s Health Center (CHC) at Zuckerberg San Francisco General Hospital (ZSFGH) is located in the Potrero Hill neighborhood of San Francisco, California. Created in 1999 in response to San Francisco’s unusually high pediatric asthma hospitalization rates, PAAC soon became the first subspecialty clinic housed within the CHC at ZSFGH. Over the years, PAAC has grown to provide comprehensive asthma and allergy care, case management, and focused education for families across San Francisco Department of Public Health (SFDPH) clinics. It also participates in asthma research efforts through its affiliation with the University of California, San Francisco (UCSF). A reflection of its surrounding community, the PAAC population is approximately 62 percent Latino, 18 percent black and 12 percent Asian, with a strong presence of immigrant families from diverse ethnic backgrounds.

As a university-affiliated public hospital serving low-income Hispanic/Latino and African-American children, ZSFGH PAAC was selected by Yes We Can: Creating an Urban Asthma Partnership to develop a comprehensive medical/social model for pediatric asthma care housed within the CHC primary care medical home. This partnership placed community health workers (CHWs) in the center of health care delivery and became the foundation of PAAC clinic services, which have grown to include legal consultation, behavioral health support and housing advocacy.

PAAC aims to provide patients with culturally sensitive and evidence-based asthma and allergy care while treating these patients and working with their families in the context of their environments. The program emphasizes individualized treatment and education, case management and family support, and home and school trigger reduction. The ability to provide quality wraparound services is due in large part to PAAC’s committed staff of physicians, nurse practitioners, nurses, CHWs and community partners. As the clinic has grown, PAAC’s CHWs have spearheaded outreach efforts to the most vulnerable community groups. To increase asthma knowledge and improve access to care, the CHWs provide trainings to foster care parent groups, daycares and schools, public health nurses, and local community organizations. PAAC also is a site of robust research in asthma prevention and intervention through its affiliation with UCSF and SFDPH.

All of PAAC’s efforts have paid off, yielding a 40 percent reduction in asthma hospitalizations in a review of data from 2015 through 2016. Qualitatively, there are many indicators of positive asthma outcomes. The number of caregivers able to appropriately describe controller and rescue medication use, as well as escalation of dose and when to seek appropriate emergency care, during a follow-up phone call at the 2 week interval has increased.

PAAC is increasingly involved in the support and development of local legislation benefiting children with asthma. In the past year, PAAC has contributed to important legislation, including a ban on smoking in public housing and a current bill to allow Medicaid reimbursement for CHWs during home visits and education. PAAC continues to advocate for environmental and social policies that promote a healthy community and a reduction in asthma prevalence.

The Le Bonheur Children’s Hospital’s CHAMP Program (Changing High-Risk Asthma in Memphis through Partnership) is a collaborative that serves children ages 2–18 in Memphis, Shelby County, Tennessee, who are identified as having high-risk asthma. Of CHAMP’s patients, 95 percent are African American children who suffer from poorly controlled asthma that results in preventable hospital and emergency department (ED) encounters, missed school days, and diminished quality of life.

Asthma affects up to 13.5 percent of children in Memphis, and it is the cause of 40 percent of Le Bonheur Children’s Hospital admissions. According to the 2010 Tennessee Discharge Data Set, almost 4,000 children were seen in emergency rooms in Shelby County for asthma-related problems. More than 600 of these children had multiple ED visits or hospitalizations, and nearly 200 required intensive care unit admissions. Pediatric asthma hospitalizations cost the Tennessee Medicaid system (TennCare) $2.1 million in avoidable hospitalizations, and an additional $2.6 million for ED visits.

The CHAMP Program—which is funded by the Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS)*—serves a subset of these patients, focusing on children who are most at risk for multiple or severe asthma exacerbations that would result in unplanned medical encounters, particularly those that take place in the ED or in the hospital (admission or observation). Although CHAMP patients have all been assigned a primary care physician (PCP), many lack a connection with their PCP, or do not consult the PCP for asthma episodes. They primarily live in rental properties characterized by environmental hazards—such as mold, mildew and cockroaches—that exacerbate asthma episodes, and many of them move frequently or spend significant periods of time in more than one residence over the course of a week or month.

CHAMP’s theory of change relies on an understanding that asthma care typically is not well managed as a result of several factors: the delivery system is fragmented; providers are unable to share information; and efforts to provide ongoing education, environmental improvements and social supports that will encourage self-management are unfocused. Building on that understanding, CHAMP created an Asthma Registry that includes medical encounter data from TennCare and medical data from electronic medical records. The CHAMP team comprises sub-specialist medical providers with significant experience in using the National Institute of Health’s guidelines for asthma diagnosis and management. CHAMP’s community-based staff members work to educate families and address barriers to self-management. Environmental concerns for at-risk patients are addressed through partnerships with families, schools, PCPs and programs/services. In addition a 24/7 call line is staffed by emergency medical technicians and registered nurses.

CHAMP’s various program components work in an integrated fashion to achieve its ambitious goals. CHAMP seeks to reduce asthma deaths among its target population to zero by June 15, 2015. In addition, the program aims to cut ED visits, avoidable hospitalizations and urgent care visits by 15 percent by June 30, 2015. By that same date, CHAMP also seeks to improve the quality of life for 80 percent of the patients, achieve an overall positive patient/family rating of the CHAMP program from at least 95 percent of the patients/families surveyed, and lower overall health care costs for children served by more than $4 million.

A distinguishing CHAMP feature is its Web-based asthma registry for high-risk patients, developed with the technological expertise of the University of Tennessee Health Science Center’s Division of Biomedical Informatics. The registry is a means of compiling and storing key pieces of information that pertain to the 55 data elements forming the core of the CHAMP quality metrics. The registry’s unique feature is that the TennCare administration allows the program to download an updated listing of all CHAMP patient encounters each month, including cost data. When CHAMP patients sign the institutional review board informed consent form, they allow the program to receive 1.5 years of TennCare medical-encounter data prior to enrollment and monthly updates every month after enrollment. This information furnishes an opportunity to use the registry as a case management tool, complete with warnings and automatic notifications that prompt CHAMP to contact families and provide help when, for example, prescriptions are not filled.

The most current data—covering the quarter ending December 31, 2014—show that the program’s 464 enrollees have seen significant gains in their asthma management. There was a 30-percent reduction (from baseline utilization) in the percentage of children who experienced at least one ED or urgent care visit per quarter. There was a 42-percent reduction in the percentage of children who have had at least one ED or urgent care visit for asthma in a 6-month period, and there was a 40-percent reduction in the percentage of children hospitalized each quarter for asthma-related diagnoses. With regard to possible reductions in cost of care, at the close of the 10th quarter, the average cost of care for each CHAMP patient per year was 52 percent less than it had been 1 year prior to CHAMP enrollment.  

Among CHAMP’s many accomplishments to date, the CHAMP Medical Director and Asthma Care Coordinators provided basic asthma education courses for all school nurses in the Shelby County system over a 2-year period (in 2013 and 2014). As for the environmental conditions of children with asthma and their families, CHAMP employs individual family interventions and collaboration with community partners to improve completing renovations and addressing concerns with laws, codes and community policies. Although still being refined, CHAMP shows great promise for meeting and exceeding the stated goals of its CMS-funded collaborative agreement.

*CHAMP is supported by Grant number 1C1CMS331046-01-00 from the Department of Health and Human Services, Centers for Medicare and Medicaid Services.  The contents of this document are solely the responsibility of Le Bonheur Children’s Hospital, Division of Community Health and Well Being and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

Tufts Medical Center (Tufts MC) is a not-for-profit academic medical center that provides health care to patients both locally in the City of Boston, Massachusetts, and regionally in surrounding communities. For the past eight years, Tufts MC's Department of Community Health Improvement Programs (CHIP) has operated the Asthma Prevention and Management Initiative (APMI) to serve a primarily immigrant, non- or limited-English speaking and densely populated Chinatown community. APMI is the only local asthma management program that focuses on and prioritizes Asian speaking families and features program components in the hospital, schools and community.

Tufts Medical Center established the APMI in 2006, in partnership with Chinatown school principals. Asthma prevalence had increased from 15 to 20 percent at the local elementary school that year (compared to a 10 percent prevalence in Boston as a whole) and Tufts MC's bilingual pediatric providers saw a spike in asthma-related urgent care visits. In response, the CHIP team set out to inform the community in places where people live, work, and gather - at day cares, elementary and secondary schools and community agencies - and educate patients and families during home visits to children with poorly controlled asthma.

In 2006, CHIP secured a Health Disparities Grant from Blue Cross Blue Shield Foundation and used the funding to initiate and sustain APMI for three years. Additional grant support from a local community development fund, The Chinatown Trust Fund, and the Department of Housing and Urban Development through the Boston Public Health Commission (BPHC), facilitated APMI's expansion to include home visits and to serve more families over time. In partnership with local elementary and secondary school principals, school nurses, Tufts MC administrators and physician champions, the CHIP director established APMI and hired its first program manager in 2006 and a bilingual Community Health Worker (CHW) in 2011. Based on a detailed assessment, conducted with input from parents with limited English skills, teachers and clinical providers, APMI developed targeted solutions for Chinatown's asthma improvement needs.

APMI developed multilingual, multimedia asthma education and self-empowerment materials that are distributed in the clinic, at schools, during home visits and in the community. In partnership with the local schools, APMI created asthma education classes and an asthma education program for local day care and community center staff, and began the development of an asthma registry connected to Tufts MC's electronic medical record system. In addition, APMI convened care providers from across the pediatric continuum - emergency, inpatient and outpatient departments, as well as local schools - to develop standardized messaging, materials and procedures to ensure children with asthma and their families hear consistent asthma care messages everywhere they receive care.

APMI also promotes prevention of asthma and improved asthma management across local neighborhoods by providing all students diagnosed with asthma, whose parents consent to their involvement, with education programs at local elementary and middle schools. APMI promotes community awareness and management of asthma, particularly how to recognize environmental triggers, by educating local parents and day care, preschool and elementary school staff in Chinatown.

Children with poorly controlled asthma who are referred to the Asthma Prevention and Management Initiative by their primary care physicians or identified by APMI staff from data in the asthma registry, receive asthma action plans and tailored and culturally and linguistically competent environmental home visits and supplies, provided by the Boston Public Health Commission. APMI currently serves more than 100 families per year through the home visit program, which includes environmental assessments, medication review, review of asthma action plans and disease education for children and their families.

APMI's home visit program is part of the broader Boston Asthma Home Visit Collaborative (BAHVC). APMI draws on and contributes to the city-wide standardized approach to in-home asthma care. Where appropriate, APMI's Community Health Worker and other home visitors make referrals to Boston's Breathe Easy at Home program - an extension of the BAHVC - for housing inspection and advocacy on behalf of tenants, and refer patients to other services to reduce environmental and social stressors, as appropriate.

To complete the circle of care and ensure communication, home visitors fill out a Home Visit Progress Note and submit it to referring clinicians after each home visit. The note also is incorporated in Tufts Medical Center's ambulatory electronic medical record and listed as a patient encounter, thus enabling clinicians to review home visit findings and reinforce CHW and home visitor interventions with patients during clinical visits. As part of the BAHVC program, APMI home visitors also share de-identified home visit information with the BPHC.

APMI tracks its progress and impact in the schools, clinic and community. After four years of delivering asthma education in schools, absences for students with asthma decreased by one day, while absences for the general elementary student population decreased by only 0.2 days. Efforts to improve clinician adherence to National Institutes of Health EPR-3 Guidelines for Asthma Care also showed impressive results. Chart review data indicate that 35 percent more children, with two or more asthma-related urgent care visits within an eight-week period, now receive appropriate controller medication prescriptions than before the clinical quality improvement effort began. For children with poorly controlled asthma, APMI can demonstrate statistically significant improvements in the home environment (i.e. reduction in the presence of triggers) and asthma outcomes (i.e. improved ACT scores, decreased hospital admissions and increased use of asthma action plans) from the first to the follow-up visit, which occurs six months later.

A partnership with BPHC's Asthma program since its inception has aided APMI's sustainability. With BPHC's encouragement and the Department of Housing and Urban Development award, APMI was able to initiate its home visiting program, which Tufts MC continues to fund. APMI also is active in advocacy efforts in Massachusetts, supporting reimbursement for asthma education and home visits by third-party payers. APMI has strong data to support this case; Outcomes data from 2009-2013 show that receiving home visits decreased urgent care visits by 21 percent and inpatient admissions by six percent, saving the health care system nearly $50,000 in avoided costs.

The Center for Pediatric Medicine (CPM) with the Greenville Health System Children’s Hospital is the major clinical provider of outpatient care for children with limited health care access in Greenville, South Carolina. A diverse community, Greenville is South Carolina’s most populous county and asthma/bronchitis is the leading cause of hospitalization for children under 18 in the area. Ninety percent of the population served at CPM receives Medicaid funding.

The Asthma Action Team (AAT) is a multidisciplinary, multilingual, family-centered program that was formed in 2008 to address increasing asthma prevalence, increasing pediatric emergency department (ED) visits and hospitalizations and ED recidivism for asthma, and growing asthma disparities in greater Greenville. The AAT is staffed by pediatricians, certified asthma educators, respiratory therapists, case managers, nurses, social workers, translators, an electronic medical record (EMR) technician, and community home visitors. Residents training in pediatrics, internal medicine, family practice and third and fourth year medical students also rotate through the AAT clinic where they learn an evidence-based approach to asthma care according to the National Asthma Education and Prevention Program (NAEPP) Guidelines for the Diagnosis and Management of Asthma.

The program strives to ensure that patients and families receive consistent asthma education and support services in clinics, homes, schools and daycares, including support for environmental asthma control, in order to promote effective self-management and avoid emergency health care utilization. The AAT coordinates with payers, local schools, community-based organizations and others to identify patients in need and to provide case management for children and adolescents with hard to control asthma. Case management includes asthma education, home visits, office visit coordination and school visits with a certified asthma educator from CPM serving as the case manager.

All AAT patients receive personalized pictorial asthma action plans written in their primary language which AAT staff review and update at every patient interaction and share with providers across the Greenville Health System (GHS) network and with school and daycare providers. The action plans are stored in the patients’ EMR and on a web-based platform where clinical providers and educators working across both inpatient and outpatient settings can access and update them. The AAT also maintains a registry and alert system to help manage 4,338 pediatric patients with asthma, to track their asthma outcomes in real time, to stratify patients for care and to ensure high quality and appropriate care is consistently delivered.

The AAT focuses on delivering comprehensive and guidelines-based clinical and environmental care everywhere people with asthma spend time. The team is acutely aware of the social, economic and cultural factors that affect pediatric asthma outcomes for the diverse community GHS serves. To help children with asthma and their family’s access appropriate clinical care and avoid emergency health care use, CPM offers extended evening and weekend hours, same day service to children experiencing asthma exacerbations, and an after-hours telephone triage line. The AAT also partners extensively to provide education, diagnostics, in-home services and social supports for environmental interventions in the community. Partners include the Family Connection of South Carolina’s Project Breathe Easy (PBE), the South Carolina Asthma Alliance, the Greenville Pediatric Asthma Community Collaborative, the Greenville County Schools and many others.

Perhaps the strongest evidence of the AAT’s impact is the fact that at the same time that the population of children with asthma in the CPM system grew by an annual rate of 63 percent, rates of ED visits for asthma declined. Data from the AAT’s partnership with PBE – which applies only to AAT clients who receive referrals to PBE – demonstrate a 71 percent decrease in urgent health care utilization, a 21 percent decrease in unscheduled clinical care visits, a 51 percent decrease in missed school days, and a 41 percent decrease in missed work days for parents post-intervention.

Mission Children’s Hospital serves the 21 most rural and isolated counties in North Carolina. This area’s  diverse minority population faces some of the greatest health disparities in the state, and further, the majorty of Mission Children’s Hopsital patients are uninsured or underinsured. Pediatric asthma, unsurprisingly, is one of these disparate health concerns.

Through an innovative and bold approach designed to meet the unique needs of this population and to impact minority children suffering from asthma in a significant way, Mission  Hospital developed the Regional Asthma Disease Management Program (RADMP). 

RADMP confronts these issues at the root of the problem — taking the clinical approach to asthma management and control into non-clinical settings, such as homes, schools and other care facilities in outlying areas. The program addresses social determinants of health, medical and environmental management, education on asthma and environmental triggers, and comprehensive care through an ever-expanding network of invested stakeholders and agencies.

In order to reach minority and low-literacy populations, RADMP utilizes population specific outreach materials and interpretive services. For low-income families, the program offers access through Mission’s Medication Assistance Program for asthma medications. Home remediation to eliminate environmental exposures is provided through RADMP’s strong network of community partners.

In 2008, the program was recognized as one of the state’s top three asthma disease management programs. In 2009, RADMP received a two-year demonstration project grant from the National Heart, Lung, and Blood Institute (NHLBI), as part of the National Asthma Control Initiative. Since 2009, RADMP activities have contributed to reducing asthma-related emergency room visits by 94 percent and hospitalizations by 95 percent, equaling a total savings of more than $800,000. In addition, the average number of school days missed by children in the program decreased from 17 to nine, indicating an increased quality of life. Statistically significant improvements were made in clinical measures including lung spirometry and eosinophilic inflammation.

In New York’s South Bronx community, one in five school-aged children has asthma — one of the highest rates in New York City. In response to this staggering statistic, Bronx-Lebanon Hospital Center’s Department of Pediatrics created the Childhood Asthma Management Program in 2000. Through clinical pediatric asthma services, community-based activities of the New York State Department of Health-funded asthma coalition, and hospital-community collaborative programming, the program promotes asthma-friendly environments and ensures the delivery of integrated health care services for children with asthma. 

Early on, program staff members recognized that to improve asthma outcomes, they must not only improve provider knowledge and communication, but also strengthen the existing health system in which providers practice. As a result, the program conducts provider training sessions that translate asthma management recommendations into quality clinical practice to ensure that patients receive comprehensive asthma services across the care continuum. Furthermore, the program engages Medicaid to provide reimbursement incentives for provider participation in asthma education. 

As the lead organization of the South Bronx Asthma Partnership, Bronx-Lebanon Hospital Center also partners with a variety of environmental agencies and community organizations to create tailored environmental interventions that address both indoor and outdoor asthma triggers. Program partners provide building walk-throughs, designate asthma-friendly zones at schools, and provide pest management assistance and air-sampling. In addition, the program distributes culturally appropriate and literacy-sensitive educational materials throughout the hospital and the community to promote patient self-management and encourage healthy behaviors in homes.

This multi-faceted approach to asthma care has resulted in tremendous success. Since 2003, Bronx- Lebanon Hospital Center has shown a 42 percent decrease in asthma-related hospitalizations, as well as a decrease in the length of stay of asthma-related hospitalizations. This equates to an annual average cost savings of about $431 per child. In addition, the National Asthma Control Initiative recently named the Bronx Lebanon partnership as a clinical champion in recognition of their efforts in promoting the Expert Panel Report 3 – Guidelines for the Diagnosis and Management of Asthma.