Health Care Provider

Mobile Care Chicago

Winner Blurb: 

Mobile Care Chicago is a not-for-profit organization that uses mobile medical clinics to assist children currently unable to access necessary specialty care for a chronic condition. For 19 years, Mobile Care Chicago has used partnerships with local schools to provide a convenient and trusted location for local children who have complex needs but whose parents may not have the time, transportation or work flexibility to access more distant brick-and-mortar clinics. Mobile Care Chicago currently operates two Asthma Vans for children with severe asthma and/or allergies, a Dental Van for children who need oral surgery, and a Portable Dental Clinic that can be set up inside of schools to make referrals to the Dental Van. In total, Mobile Care Chicago’s mobile clinics serve roughly 8,000 patients per year, seeing the vast majority multiple times per year.

Research suggests that in lower income Chicago neighborhoods, such as Humboldt Park and the South Shore, more than 25% of children have asthma. Chicago has the second-most asthma fatalities of all cities in the United States, according to the Asthma and Allergy Foundation of America. Most fatalities happen in Cook County neighborhoods where asthma is not well-controlled because of lack of available medical care. The Illinois Department of Public Health estimates that 76.5% of children with asthma in Illinois qualify as “not well-controlled, with the vast majority of cases reported in low-income areas.” 

Asthma Vans go directly into lower income communities where specialty care access is an issue. The Asthma Vans then provide ongoing medical support to children with asthma, with a focus on adopting the medical care of its patients from their first appointment until the child turns 19 or graduates from high school. The average patient currently stays with their Asthma Van for more than 7 years. Mobile Care Chicago has screened more than 125,000 children for asthma in its 19-year history and provided comprehensive asthma care to more than 12,000 vulnerable children through more than 44,000 patient visits.

In recent years, Mobile Care Chicago has focused on high-intensity interventions for children with the most severe asthma/allergy conditions, including some children who had been cycling through local emergency departments more than 50 times per year. Through a team of nurse practitioners, allergists and community health workers, the Asthma Vans provide a series of home environment assessments, direct medical treatment and therapy, telemedicine and telehealth support for families, on-going education, and a 24-hour hotline staffed by the nurse practitioner team. The 3-year pilot of this high-intensity asthma control method reduced pediatric asthma emergency room visit rates by 84% in one Chicago hospital that previously had one of the highest rates of asthma admittances.

Patients assisted through the Asthma Vans have seen a more than a 50% decrease in school absenteeism and emergency department visits. Last year, only 6% of Asthma Van patients used an emergency room, versus 55% in the year prior to enrollment. The reduction in hospitalization rate alone (19% to 2% for Mobile Care Chicago patients) has saved the local health care system at least $156 million during the past 13 years. In addition, the Illinois Department of Public Health estimates that uncontrolled asthma costs the state of Illinois $15,155 per individual. By contrast, Mobile Care Chicago spent an average of $836 on each patient in the last fiscal year. This represents a 94% savings for each patient whose asthma is controlled.

Mobile Care Chicago’s early intervention screenings and mobile medical care delivery in hard-to-access and low-income communities has encouraged action and change in the surrounding Chicago communities, bringing asthma relief for thousands of children and peace of mind for parents.

Winnner Photo: 
Winner Photo Caption: 

From left to right: Amy Bain, CPNP; Jorge Mendoza (van driver); Elizabeth Lemus (Asthma Program Manager); Kamari Thompson (Community Health Worker); Dr. Andrea Pappalardo (Allergist); Sandra Morales (MA); Raul Hernandez (van driver)

Award Winner Category: 
Award Year: 

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

Award Winner Category: 
Award Year: 

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.

Award Winner Category: 
Award Year: 

Pages