Health Care Provider

The Pediatric Asthma and Allergy Clinic at Zuckerberg San Francisco General Hospital

Winner Blurb: 

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.

Winnner Photo: 
Winner Photo Caption: 

Christine Mayor, PNP, Kimberlee Honda, FNP, Silvia Raymundo, CHW, Stephanie Williams, CHW and Justina Bocanegra, CHW of the Pediatric Asthma & Allergy Clinic at Children`s Health Center at Zuckerberg San Francisco General

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Children’s Hospital of Richmond at Virginia Commonwealth University

Winner Blurb: 

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. 

Winnner Photo: 
Winner Photo Caption: 

Kathleen Bowden, Dr. Michael Schechter, and Ginger Mary of the UCAN Program in the Division of Pediatric Pulmonology at Children’s Hospital of Richmond at VCU.

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Urban Health Plan(UHP)

Winner Blurb: 

Urban Health Plan (UHP) is a network of nine community health centers and nine school-based health centers located in the South Bronx, NY—the poorest congressional district in the country—and in Corona, Queens, NY. Located within UHP’s catchment area, in Hunts Point, Bronx, is the largest food distribution center in the country. As a result of the traffic and pollution generated by the trucks used to distribute food, Hunts Point has one of the highest asthma rates in New York City. Due to the incidence and prevalence of asthma in this area, and because many of UHP’s patients are unaware that they have asthma, early diagnosis is critical. By integrating asthma care into primary care, all patients are screened for asthma every 6 months, including those with no history of asthma. In 2009, 1,000 patients were screened and 22 percent were diagnosed with asthma.

 

Asthma Relief Street, UHP’s asthma management program, cares for more than 12,000 people with asthma using a multidisciplinary program that is fully integrated into its primary care practice. The primary care provider, health educator and medical assistant (MA) work closely with UHP’s allergists, pulmonologists, social service workers and the integrated pest management program, as well as with New York City Asthma Intervention and Relief (a.i.r. nyc), to provide integrated health care services.

 

UHP has created long-lasting relationships with community organizations and has partnered with local hospitals and the neighborhood’s shelters to provide support and asthma education to their constituencies. UHP works closely with the New York City Department of Health’s New York City Asthma Partnership, a citywide coalition that brings together more than 400 community-based organizations and individuals to make recommendations to improve citywide policies and systems that affect people with asthma. This partnership is coordinated by the New York City Asthma Initiative.

 

UHP has developed a unique workflow algorithm to help identify patients and optimize appropriate treatment and followup. Any patient who visits UHP for primary health care services, whether he or she is an asthma patient or not, meets with an MA who ask a series of questions about asthma and asthma risks, following UHP’s asthma template or asthma-screening template. This visit with the MA is followed by a visit with the primary care provider, who reviews the patient’s responses to the MA’s questions about signs and symptoms and the Asthma Control Test, focusing on medication use; reviews and updates the patient’s Asthma Action Plan as needed; and answers any patient questions. Following the visit with the provider, a health educator holds a counseling session with the patient and reviews five asthma lesson plans: (1) definition of asthma (2) the signs symptoms of exacerbations (3) recommendations on remediation in the home to address environmental triggers (4) differences between "controller" and "rescue" medications (5) and understanding of spirometry and exhaled nitric oxide. Health educators also address any concerns the patient might have about asthma management. This process is repeated during all visits.

 

UHP’s goal is to empower patients and families to better manage their illness, so patients are encouraged to set self-management goals with the asthma health educator. The five-lesson asthma curriculum, which was developed by UHP clinicians, is used to educate both patients and their families. Using a self-management tool box that includes placebo medications, spacers, peak flow meters, masks, and sample Asthma Action Plans (AAPs), the health educator provides hands-on demonstrations on how to use the metered dose inhalers, dry powdered inhalers and nebulizers. Through an arrangement with various vendors, nebulizer compressors and aerochambers are provided to patients who need this equipment for treatment at home. This allows the health educator to provide hands-on demonstrations on how to use the machine and to provide cleaning and storage instructions to patients.

 

As of December 2015—

  • 89 percent of UHP’s patients have had a severity assessment.
  • 99 percent of patients with a severity assessment of “persistent asthma” are treated with anti inflammatory medications.
  • 50 percent of UHP’s patients have documented self-management goals.
  • 56 percent of UHP’s patients receive the influenza vaccine each year.
  • 3 percent of UHP’s patients had urgent care or emergency department visits in the previous 6 months and an average of 11 symptom-free days and 0.156 work/school days lost per month.
Winnner Photo: 
Winner Photo Caption: 

The Urban Health Plan Asthma team: Back row: Caridad Taura, health educator; Samuel DeLeon, MD, Chief Medical Officer and Senior Vice President for Medical Affairs. Front row: Health educators Grace Baez, Vanessa Montanez and Kelly Chacon; Acklema Mohammad, MD, Chair, Pediatrics and asthma physician champion; Christine Torres, health educator.

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