Integrated Health Care Services

Strategy 1 - Educate and Support Clinical Care Teams
Encourage providers to deliver care consistent with national guidelines by educating them, possibly through physician champions, and giving them tools to facilitate consistent, high-quality care
Strategies in Action:
  • CMFHP delivers asthma education to all staff at plan-affiliated clinics. Certified asthma educators provide 8 weeks of on-site training in asthma diagnosis and assessment, environmental management of triggers, and guidelines for treatment. The training helps ensure consistency in care from practice to practice.
  • Monroe trains new medical residents on asthma care guidelines.
  • Providers receive at least 4 education sessions through CAPP’s training program, and a clinical coordinator visits all sites every week for 3 to 6 months to conduct case reviews and asthma care education. Providers can also submit their cases for review by the CAPP Program Director.
Strategy 2 - Support Continuous Clinical Improvement
Monitor the delivery of asthma care and use data to regularly update clinical teams on their performance and how they can improve their delivery of asthma care
Strategies in Action:
  • UHP uses asthma-severity classification forms to promote care improvement. Program leaders train clinical teams on how and why to use the form (i.e., the health outcomes they can achieve). UHP tracks providers’ use of the form, shares monthly outcomes data with each care site, and highlights results from sites that use the form consistently.
  • When providers over estimated the percentage of their patients classified for asthma severity, CHA’s leaders conducted chart audits and put the actual percentages in front of providers. CHA shares monthly outcomes data with all providers and uses the data to demonstrate the difference in outcomes between those practices that engage fully in the Planned Care Model and those following outdated clinical strategies.
Strategy 3 - Promote Robust Patient/Provider Interaction
Look for ways to create strong relationships between asthma patients and their care teams
Strategies in Action:
  • UHP trains their asthma educators on the national guidelines for asthma care and motivational interviewing techniques and stations educators at the point of care. Sixty percent of UHP’s asthma patients have self-management goals they developed in consultation with their providers, health educators, and medical assistants.
Strategy 4 - Facilitate Communication Across the Care Team
Forge connections between service providers to ensure communication and coordination of asthma care across the team
Strategies in Action:
  • Monroe’s asthma outreach staff attends clinical visits with families to coordinate home-based and clinical care, share the results of home assessments, and work with providers on environmental management.
  • Case managers, social workers, and asthma educators from ANWM regularly meet with providers to refine asthma management plans. Case managers also share information with schools and health plans.
  • CHA’s asthma registry is an effective communication tool because schools, clinics, hospitals, outreach workers, and other members of the team can access it and be in a real-time conversation about patient care.