Organizing a Sustainable System of Care for Children with Asthma

1. Organizing a Sustainable System of Care for Children with Asthma DC Asthma Coalition Lisa A. Gilmore, Project Director 202-682-5864 lgilmore@aladc.org

2. The Vision • Focus on modeling effective interventions for inner-city asthma populations • Define and measure three key outcomes: reduced ER and hospital visits, reduced school absences, improved quality of life for children and their caregivers • Foster partnerships for collaborative interventions • Use collaborative case management to reach kids through core institutions: hospitals, clinics, family health centers, schools, daycare, places of worship, rec. centers, public housing • Measure: study participant outcomes, coalition process and activities, community outcomes, degree of family empowerment

3. 5 Strategic Pillars • Direct individual interventions • 229 study participants (400 before attrition) • Referrals primarily from case-management based partners (e.g., family health centers, clinics, mental health centers) • Extensive home visit and follow-up program • Asthma Management Plan developed, implemented, and shared • Extensive data sharing among partners • Targeted education (workshops, staff training, more) • Comprehensive community-wide education campaign • Electronic platform for tracking and collaboration • Public policy

4. Key Challenges • Developing and implementing a comprehensive action plan • Developing means for measuring success, and for coordinating activities

5. The Process • Build a coalition consensuson intermediate outcome objectives (e.g., all study participants receive home visits and case worker support) • Develop a comprehensive flow chart to map mechanisms for implementing agreed objectives • Implement each elementof the overall strategic map, in conjunction with key partners and using a wide range of community resources • Measure and track all activitiesto support development of best practices model

6. Home Visits. Summary Slide DCAC Asthma Action Plan Home Visits. Summary Slide Partner agencies Other sources External link Initial home visit Planning Referrals Initial home visit Subsequent contacts Parent signs releases Assessment (see slide 2) Meets study criteria Tracking Fails criteria Tracking: Interim database + Electronic Tracking System Outward referral Asthma Management Plan (AMP) Interventions (see slide 3) CHWs, Asthma Counselors Medical plan (from MD) Annual assessments Subsequent contacts • Communicated to other partners • Schools • Daycare, etc Type II Participant Type III Participant Type I Participant Ongoing assessments and event monitoring Check in by phone Check in: phone One follow-up visit Check in: phone Two follow-up visits Parent support groups and other resources

7. Schools DCAC Asthma Action Plan The Schools School Administration All kids Pre- screening Possibly asthmatic Enroll in OAS OAS: six-week program on behavior mod. for kids Full doctor screening Allergy specialist Policy Action Items: Kids and meds. in schools Getting Medical Action Plan into school records Asthma Diagnosis Recruit into study Camp Happy Lungs Howard U. Study Allergy policy Policy on donations to schools Medical Action Plan Individual Activity Program Nurse response Legend: Event response plan Front-line teacher response Back-up response All Training Some OAS Training Initial response plan – all teachers Asthma Training Nurses + Asst.Prin. Major component Large Bold Environment School assessment Limited remediation plan Tools for Schools Remediation action

8. Measuring Success • Participant outcomes: Measurable improvement in ER/hospital visits, school absences, quality of life • Process outcomes: • Measure interventions by DCAC staff – home visits, participant training sessions, staff trainings, AMP development process • Measure coalition participation: meetings attended, staff committed to DCAC initiatives, education partnerships, etc. • Measure improved self-management of asthma • Community outcomes: Measure increased awareness of asthma, and community responses for addressing it (e.g., school response plans) • Policy outcomes: • Measure development of specific policy objectives (e.g., medication available in schools) • Measure extent to which desired policy changes are addressed by policy makers and are then successfully adopted

9. Tracking and Measurement Other data sources Environmental Demographic Economic Patient data ER Daycare DCAC counselors Clinics Partner agency case workers Head Start Electronic Tracking System Schools Coalition process and activities Aggregate data Model

10. Process and Philosophy • Based entirely on coalition-building principles • Extensive partnerships and outreach • Coordinating use of others’ resources • Deep consultation and consensus building • Substantive and substantial participation in planning and decision-making by coalition partners • Careful planning a key condition for effective action • “What gets measured gets done” – commitment to comprehensive tracking and evaluation