Health Care Provider

Children's Mercy Hospitals and Clinics — serving families in Nebraska, Oklahoma, Kansas, and Missouri — uses a creative approach for managing pediatric asthma. Children's Mercy trained a team of asthma educators to implement a three-part environmental asthma management program that included education for providers and staff; personalized case management and education for families with high hospital utilization due to asthma; and in-home, school, and day care environmental assessments to determine the presence of asthma triggers. Children's Mercy determined that for those patients with severe cases of asthma, home-based, hands-on education about the common environmental asthma triggers was critical to ensuring that patients gained control over their asthma and made the connection between their asthma symptoms and environmental triggers in their home environment. During the home assessments, Children's Mercy staff conducts a comprehensive environmental and safety assessment that identifies common environmental asthma triggers. Based on the home assessments, asthma educators provide personalized environmental health action plans to help patients and their families identify their asthma triggers and to reduce these triggers in their home. Through a creative partnership with the Healthy Homes Network for Kansas City, and funded by a HUD Healthy Homes Demonstration grant, qualifying families are provided up to $2,000 worth of home supplies and repairs to try to reduce environmental asthma triggers. As a result of Children's Mercy's efforts, patients and their families know more about what triggers their asthma and how to control asthma symptoms. Children's Mercy has seen fewer emergency department visits and hospitalizations since the program's inception.

Improving Pediatric Asthma Care in the District of Columbia (IMPACT DC) Asthma Clinic targets inner-city, minority and disadvantaged children who suffer disproportionate asthma morbidity and mortality. Most live with challenging social and environmental circumstances with daily exposure to multiple asthma triggers. Their families often have a tenuous connection with their primary care providers, and thus frequently rely on emergency departments (EDs) for asthma care. While EDs typically provide excellent episodic care for acute asthma exacerbations, they usually pay little attention to longitudinal management issues. As a result, many families view asthma as an episodic problem instead of a chronic disease requiring daily management. IMPACT DC's fully validated program recruits from a large urban ED (Children's National Medical Center) and focuses on three distinct domains: environmental control, medical management, and longitudinal care. In a prospective clinical trial, it improved multiple patient outcomes. It is an innovative, replicable, and cost-efficient national model for asthma mitigation among children in the inner city.

MaineHealth's service area covers 90,675 patients with asthma, including 27,156 children in southern, central, and western Maine. The AH! (Asthma Health) Program combines standards-based clinical care with robust indoor and outdoor environmental asthma management. Patients receive counseling to manage exposures to environmental triggers in home, school and work settings. The AH! Program has a strong presence outside its clinical settings, having built long-term relationships with community organizations, schools and daycare centers, public health departments, and others. The AH! Program also takes leadership positions to advocate for municipal, state, or national public policy actions—such as bans on tobacco use in public places—that create asthma-friendly environments. The results of these impressive efforts have reduced emergency room use, hospitalizations, and missed school and work days, and improved physician adherence to national guidelines for asthma care. Evaluations at six months post-intervention show a 61 percent reduction in appropriate emergency room use and a 29 percent reduction in hospitalizations. Maine Medical Center, one of MaineHealth's member hospitals, achieved a reduction in emergency room visits from 81 percent to 20 percent and hospitalizations from 32 percent to 3 percent. These improved outcomes resulted in 2006 avoided costs of $61,635 on emergency room visits and $411,470 on hospitalizations.

The University of Michigan Health System (UMHS) is a non-profit health care provider serving 12,214 adults and children with asthma in Southeastern Michigan. Since 2005, the UMHS Quality Improvement Steering Committee, a group of multidisciplinary volunteers, has guided improvements in asthma care across the health system. UMHS provides specific, population-based programs for high-risk asthma populations and in-home asthma education through the Michigan Visiting Nurses Asthma Home Environmental Assessment Program. Web-based, standardized NHLBI-compatible guidelines are available to all providers, including standardized asthma action plans and education templates. A comprehensive, validated, all-payer database of asthma patients helps UMHS identify areas of need for targeting interventions and assessing outcomes. As a result of these programs, UMHS achieved a 50 percent decrease in asthma-related hospitalizations among participants in the Children’s Asthma Wellness Program from July 2005 to June 2007. Between June 2006 and June 2007, participants in the home assessment program had a 60 percent decline in ED visits and an 85 percent decrease in hospitalizations.

The Seton Family of Hospitals formed the Seton Asthma Center in 2004 to respond to a rise in asthma-related pediatric emergency department visits and hospitalizations, especially among economically disadvantaged and underserved populations. The Center’s case management workers, all registered respiratory therapists, promote improved patient self-management in bilingual patient education sessions that include in-home environmental assessments, training on appropriate use of medications and peak flow meters, and the development of personalized asthma action plans. The asthma action plan serves as a communication tool between the primary care provider, the school nurse, and the patient. The case managers review each asthma action plan quarterly to ensure each patient has a current, effective plan in place. The Center also operates a mobile caravan that makes monthly visits to public schools to deliver asthma care to uninsured and indigent students. Case managers have partnered with the Central Texas Asthma Coalition and the American Lung Association’s Lung Health Initiatives Committee to raise public awareness, educate providers, and collect surveillance data. This partnership has led to the use of a standardized set of metrics to assess the burden of asthma in the community. For patients enrolled in the program, asthma-related emergency department visits have dropped by 75 percent, and the number of in-patient visits has decreased by 85 percent.

Staffed by pulmonologists, allergists, public health staff, and an extensive translation services program—with over 30 languages spoken—Boston Medical Center’s (BMC) collaboration with the Boston Public Health Commission (BPHC) provides excellent clinical and environmental care and promotes improved asthma self-management for the city’s underserved populations. The program educates patients about asthma management and environmental triggers, facilitates access to needed services (medical legal partnership, housing, and insurance), and promotes strong provider-patient relationships that contribute to improved patient outcomes. BMC’s environmental focus includes partnerships with several Boston agencies to launch the Breathe Easy at Home Program, a Web-facilitated program that gives health professionals a way to report potential housing code violations that may worsen patient asthma, and the Boston Inspectional Services Department responds to reports by working with property owners to remediate the situation. In striving to offer effective and accessible primary care and outpatient services, BMC successfully works with their most utilized health plans to provide asthma education and case management services and provides exceptional care without exception. The city of Boston is reaping the benefits of this powerful collaboration. The hospitalization rate for Boston’s children with asthma has decreased 39 percent and emergency department visits are 16 percent lower.

Twelve years ago, the Woodhull North Brooklyn Health Network implemented its comprehensive, evidence-based asthma management program to ensure best practices for asthma care were used to treat all asthma patients. By educating and training health care providers, community organizations and schools, Woodhull has taken a multi-faceted approach to improving asthma care in one of the nation’s highest-risk communities for asthma. At the center of this approach is the Network’s leadership in heading the North Brooklyn Asthma Action Alliance, a coalition that partners with national organizations, community groups and health care facilities to deliver a high standard of asthma care to the community. Supporting this work, the program trains doctors, nurses and hospital residents with its PACE program, which aligns with the National Institutes of Health Guidelines for Asthma Care, and utilizes a modified Electronic Health Record to ensure that all of Woodhull’s providers deliver Guidelines-based care. In partnership with Rutgers University, Woodhull performs ground-breaking education on environmental triggers to schools, including the distribution of checklists and diagrams outlining the process to eliminate common triggers. Woodhull also addresses patients’ home environments, distributing environmental control products such as allergen-proof pillow and mattress covers free of charge. Woodhull has renovated the emergency department with a state-of-the-art asthma treatment room, which offers patients assistance with their paperwork while they begin treatment.

This fast-track approach has resulted in easier and more effective access to asthma treatment in emergency situations. The results of Woodhull’s work are captured in its Asthma Registry: The number of visits to the pediatric asthma clinic more than doubled between 2008 and 2009, which correlated to a 58 percent reduction in asthma-related emergency department visits and 67 percent decrease in hospitalizations.

Children’s Hospital Boston developed the Community Asthma Initiative (CAI) in 2005 in response to alarmingly high rates of asthma among children living in Boston’s urban neighborhoods, especially underserved children and families. CAI is a patient-centered program that provides bilingual (Spanish) in-home family asthma education, environmental assessments and remediation; Integrated Pest Management; and coordination with primary care providers, in conjunction with community education, outreach and advocacy. Care is provided and coordinated through a culturally appropriate case management model that identifies barriers to good asthma control and includes home visits conducted by nurses and/or community health workers, depending on the family’s needs. To ensure it provides the services and information the community needs most, CAI convenes a Family Advisory Board. In response to the Family Advisory Board’s vision, CAI delivered an Asthma Community Forum, with over 100 attendees discussing asthma-related issues, including environmental management in homes and schools. CAI also offers educational programs and activities for community-based organizations, schools and provider groups. For example, CAI, along with the Boston Public Health Commission (BPHC), hosts the Boston Asthma Swim Program, which provides children with asthma the opportunity to engage in physical activities while learning about asthma control. To improve insurance coverage for case management and home visits—and to increase access to affordable medications and reimbursements—CAI works closely with the Office of Government Relations at Children’s Hospital Boston, BPHC and community partners, providing support for policy and system changes. The Initiative has achieved impressive results. For CAI patients, asthma-related emergency department visits have dropped by 65 percent and hospitalizations have decreased by 81 percent. Further, CAI calculated a 146 percent return on investment (ROI) to society due to lower hospital costs. Enrolled families have also reported a reduction in the limitation of physical activity (37 percent), asthma- related school absences (39 percent), and asthma-related work absences (49 percent).