Area 1: Comprehensive Asthma Management Program

In this section, describe your comprehensive asthma program, including your program’s management structure and operating principles (1.a) as well as the integrated health care services (1.b), and tailored environmental interventions (1.c) your asthma program provides. Highlight high-performing collaborations that contribute to your success, and discuss your approach to reducing asthma disparities in the community you serve.

1.a Management Structure and Operating Principles (20 points)

  • Describe your organization.
  • Describe the demographics of the population impacted by your asthma program.
  • Describe the origin and evolution of your asthma program.
Application GuidelinesEvaluation Criteria
  • Describe your health plan and its distinguishing features.
  • Describe the population served by your comprehensive asthma pgoram. Please be as specific as possible. For example, include average age, ethnicity, languages spoken, income, etc.
  • Describe when and how your asthma disease management program began and how it changed over time. What needs did you recognize in the population you serve and how did you organize to address those needs? What additional services have you added to identify new patients and help patients control asthma?
  • Describe who championed the asthma program's evolution and how change occurred.
  • The applicant identified main components of the program and the program's mission, vision, goals and objectives.
  • The applicant presented any honors, awards or distinctions previously awarded to the program.
    • Example:"Nurtur is also the first health management organization to receive H-TAP (Healthcare Transparency Accreditation Program) Accreditation from the Population Health Impact Institute for its five chronic disease management programs, recognizing the company's statistical validity, quality, and transparency to clients in its outcomes reporting."
  • Staff demonstrates knowledge of asthma-related services and implementation of health care plans
  • The program understands its target audience and the demographics of its community.
  • The program's population demonstrates need for asthma-related services (high asthma rates, low SES, etc.)
    • Example:"Asthma disproportionately affects the Hispanic population...This population has more problems managing their asthma, including seeking less care from their Primary Care Provider (PCP) or a specialist and having less care prescriptions for asthma medicines. LA Cares About Asthma® is made up of 46.2% Spanish-speaking members. All of the program's asthma nurses are bi-lingual, and coordination with the Health Education/Cultural & Linguistics department ensures asthma materials are culturally and linguistically appropriate."
  • The program makes services accessible to its target community and employs approaches to increase patient participation in programs (e.g., targeted outreach, incentives for participation in program components, accessible office locations and hours).
  • Strategy and goals are comprehensive (i.e., address both medical and environmental management) and are aligned with the community’s asthma care needs.
  • Program continually assesses and refines its service offerings and delivery based on feedback from the target community.
  • Applicant identified and encouraged leaders and champions who helped to establish, build and promote the asthma program.

1.b Integrated Health Care Services (20 points)

Describe the partners that comprise the system of care you provide patients and their families in the asthma disease management program.

Application GuidelinesEvaluation Criteria
  • Describe program tools and strategies that address common barriers to access and treatment adherence and that reduce health disparities among your Medicare, Medicaid and commercial patients.
  • Describe the ways in which you partner with providers, vendors, community organizations, federal and/or state agencies, etc., to ensure a coordinated approach to facilitating comprehensive asthma care and improve patient outcomes.
  • Describe the communication system that is in place to ensure a coordinated approach.
  • Applicant addresses health and socioeconomic disparities in the community and explains how the program targets those disparities in an innovative and effective manner.
    • Example: "Because many of the barriers for medical care in Medicaid are the result of lack of social support and safe housing, we have developed an aggressive care coordination program to ensure our patients have such basic services as transportation to the doctor, electricity for their nebulizer, and a clean home environment."
  • Program takes action to continuously ensure strong community ties by participating in local organizations and activities, hiring from the local community and including community stakeholders in program planning and implementation.
  • High-performing collaborations and partnerships help to achieve the program’s goals, gain credibility within the target community, ensure delivery of services and leverage resources.
  • Program demonstrates centralized methods to collect, coordinate, manage and share information on patient enrollment, diagnoses, stratification, treatments and treatment plans, referrals, utilization and outcomes across health care teams.
    • Example: "Since 2010, L.A. Care has generated and distributed individual physician reports that include a list of physicians’ assigned members who have recently visited CHLA ER, along with members’ diagnosis information. The QI Director presented this initiative at the Fall 2011 National Association of Healthcare Quality conference to demonstrate an initiative of collaboration to reduce ER utilization."

1.c Environmental Services (30 points)

Describe the components of your asthma program that address environmental management.

Application GuidelinesEvaluation Criteria
  • Describe the range of environmental-focused services and interventions that are available to address asthma patients’ at different risk levels. Examples of services may include provider-based or home-based self-management education; outreach to increase awareness and control of environmental asthma triggers via telephonic case management; home environmental remediation assessment; home equipment or supplies; and other environmental management strategies.
  • Explain who conducts the services, the frequency of contact and duration of engagement, and the information that is communicated between the home visitors and the provider.
  • If your program has an in-home intervention component, what percentage of patients in your asthma program receives in-home interventions?
  • Environmental management is addressed throughout the continuum of care.
  • NIH EPR-3 Guidelines are incorporated throughout the continuum of care, and the program assesses asthma severity to initiate therapy, provides self-management education and encourages use of an asthma action plan, integrates education into all points of care where health professionals interact with patients and selects medication and delivery devices to meet each patient's need and circumstances.
    • Example:We have partnered with a nationally known author, Michelle Bain, to create a book for teens that address asthma awareness and management, Off the Chain - It's All About Asthma...The publication provides practical information on controlling asthma, including avoidance of environmental triggers and the impact of environmental factors. The book is written with the intent to appeal to a diverse group of ethnicities, personalities and interests. All images and graphics are designed to be very topic specific, memorable and humorous to the teen reader. Additionally we offer our comprehensive asthma book, On Target with Your Asthma. Both books are available in English and Spanish, as well as in an audio format that can be loaded onto MP3 players or smart phones to be listened to at the member's convenience.
  • The program provides follow up to initial environmental assessment to ensure adherence to recommendations and comprehension of educational materials.
  • The applicant identifies mechanisms to ensure effective and timely communication and collaboration among multidisciplinary teams (e.g., primary care physicians, specialists, case managers, community partners) responsible for implementing the comprehensive asthma program.