Health Care Provider

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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The Le Bonheur Children’s Hospital

Winner Blurb: 

The Le Bonheur Children’s Hospital’s CHAMP Program (Changing High-Risk Asthma in Memphis through Partnership) is a collaborative that serves children ages 2–18 in Memphis, Shelby County, Tennessee, who are identified as having high-risk asthma. Of CHAMP’s patients, 95 percent are African American children who suffer from poorly controlled asthma that results in preventable hospital and emergency department (ED) encounters, missed school days, and diminished quality of life.


Asthma affects up to 13.5 percent of children in Memphis, and it is the cause of 40 percent of Le Bonheur Children’s Hospital admissions. According to the 2010 Tennessee Discharge Data Set, almost 4,000 children were seen in emergency rooms in Shelby County for asthma-related problems. More than 600 of these children had multiple ED visits or hospitalizations, and nearly 200 required intensive care unit admissions. Pediatric asthma hospitalizations cost the Tennessee Medicaid system (TennCare) $2.1 million in avoidable hospitalizations, and an additional $2.6 million for ED visits.


The CHAMP Program—which is funded by the Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS)*—serves a subset of these patients, focusing on children who are most at risk for multiple or severe asthma exacerbations that would result in unplanned medical encounters, particularly those that take place in the ED or in the hospital (admission or observation). Although CHAMP patients have all been assigned a primary care physician (PCP), many lack a connection with their PCP, or do not consult the PCP for asthma episodes. They primarily live in rental properties characterized by environmental hazards—such as mold, mildew and cockroaches—that exacerbate asthma episodes, and many of them move frequently or spend significant periods of time in more than one residence over the course of a week or month.


CHAMP’s theory of change relies on an understanding that asthma care typically is not well managed as a result of several factors: the delivery system is fragmented; providers are unable to share information; and efforts to provide ongoing education, environmental improvements and social supports that will encourage self-management are unfocused. Building on that understanding, CHAMP created an Asthma Registry that includes medical encounter data from TennCare and medical data from electronic medical records. The CHAMP team comprises sub-specialist medical providers with significant experience in using the National Institute of Health’s guidelines for asthma diagnosis and management. CHAMP’s community-based staff members work to educate families and address barriers to self-management. Environmental concerns for at-risk patients are addressed through partnerships with families, schools, PCPs and programs/services. In addition a 24/7 call line is staffed by emergency medical technicians and registered nurses.

CHAMP’s various program components work in an integrated fashion to achieve its ambitious goals. CHAMP seeks to reduce asthma deaths among its target population to zero by June 15, 2015. In addition, the program aims to cut ED visits, avoidable hospitalizations and urgent care visits by 15 percent by June 30, 2015. By that same date, CHAMP also seeks to improve the quality of life for 80 percent of the patients, achieve an overall positive patient/family rating of the CHAMP program from at least 95 percent of the patients/families surveyed, and lower overall health care costs for children served by more than $4 million.


A distinguishing CHAMP feature is its Web-based asthma registry for high-risk patients, developed with the technological expertise of the University of Tennessee Health Science Center’s Division of Biomedical Informatics. The registry is a means of compiling and storing key pieces of information that pertain to the 55 data elements forming the core of the CHAMP quality metrics. The registry’s unique feature is that the TennCare administration allows the program to download an updated listing of all CHAMP patient encounters each month, including cost data. When CHAMP patients sign the institutional review board informed consent form, they allow the program to receive 1.5 years of TennCare medical-encounter data prior to enrollment and monthly updates every month after enrollment. This information furnishes an opportunity to use the registry as a case management tool, complete with warnings and automatic notifications that prompt CHAMP to contact families and provide help when, for example, prescriptions are not filled.


The most current data—covering the quarter ending December 31, 2014—show that the program’s 464 enrollees have seen significant gains in their asthma management. There was a 30-percent reduction (from baseline utilization) in the percentage of children who experienced at least one ED or urgent care visit per quarter. There was a 42-percent reduction in the percentage of children who have had at least one ED or urgent care visit for asthma in a 6-month period, and there was a 40-percent reduction in the percentage of children hospitalized each quarter for asthma-related diagnoses. With regard to possible reductions in cost of care, at the close of the 10th quarter, the average cost of care for each CHAMP patient per year was 52 percent less than it had been 1 year prior to CHAMP enrollment.  


Among CHAMP’s many accomplishments to date, the CHAMP Medical Director and Asthma Care Coordinators provided basic asthma education courses for all school nurses in the Shelby County system over a 2-year period (in 2013 and 2014). As for the environmental conditions of children with asthma and their families, CHAMP employs individual family interventions and collaboration with community partners to improve completing renovations and addressing concerns with laws, codes and community policies. Although still being refined, CHAMP shows great promise for meeting and exceeding the stated goals of its CMS-funded collaborative agreement.


*CHAMP is supported by Grant number 1C1CMS331046-01-00 from the Department of Health and Human Services, Centers for Medicare and Medicaid Services.  The contents of this document are solely the responsibility of Le Bonheur Children’s Hospital, Division of Community Health and Well Being and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.

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Winner Photo Caption: 

1st row – Christina Watkins-Bolden, Alexandria Bagley, Teresa Hughes, Dr. Christie Michael, Susan Steppe, Stephanie Watson, Linda Mallory, and Mark Sakauye
2nd Row – Regina Perry, Yvonne Elliott, Dr. Dennis Stokes, Raisha Montgomery, Karen Nellis, and Kelli Holloway
3rd Row - Dr. Christina Underhill, Beverly Brown, Tabatha Johnson, and Emin Kuscu

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Tufts Medical Center

Winner Blurb: 

Tufts Medical Center (Tufts MC) is a not-for-profit academic medical center that provides health care to patients both locally in the City of Boston, Massachusetts, and regionally in surrounding communities. For the past eight years, Tufts MC's Department of Community Health Improvement Programs (CHIP) has operated the Asthma Prevention and Management Initiative (APMI) to serve a primarily immigrant, non- or limited-English speaking and densely populated Chinatown community. APMI is the only local asthma management program that focuses on and prioritizes Asian speaking families and features program components in the hospital, schools and community.


Tufts Medical Center established the APMI in 2006, in partnership with Chinatown school principals. Asthma prevalence had increased from 15 to 20 percent at the local elementary school that year (compared to a 10 percent prevalence in Boston as a whole) and Tufts MC's bilingual pediatric providers saw a spike in asthma-related urgent care visits. In response, the CHIP team set out to inform the community in places where people live, work, and gather - at day cares, elementary and secondary schools and community agencies - and educate patients and families during home visits to children with poorly controlled asthma.


In 2006, CHIP secured a Health Disparities Grant from Blue Cross Blue Shield Foundation and used the funding to initiate and sustain APMI for three years. Additional grant support from a local community development fund, The Chinatown Trust Fund, and the Department of Housing and Urban Development through the Boston Public Health Commission (BPHC), facilitated APMI's expansion to include home visits and to serve more families over time. In partnership with local elementary and secondary school principals, school nurses, Tufts MC administrators and physician champions, the CHIP director established APMI and hired its first program manager in 2006 and a bilingual Community Health Worker (CHW) in 2011. Based on a detailed assessment, conducted with input from parents with limited English skills, teachers and clinical providers, APMI developed targeted solutions for Chinatown's asthma improvement needs.


APMI developed multilingual, multimedia asthma education and self-empowerment materials that are distributed in the clinic, at schools, during home visits and in the community. In partnership with the local schools, APMI created asthma education classes and an asthma education program for local day care and community center staff, and began the development of an asthma registry connected to Tufts MC's electronic medical record system. In addition, APMI convened care providers from across the pediatric continuum - emergency, inpatient and outpatient departments, as well as local schools - to develop standardized messaging, materials and procedures to ensure children with asthma and their families hear consistent asthma care messages everywhere they receive care.


APMI also promotes prevention of asthma and improved asthma management across local neighborhoods by providing all students diagnosed with asthma, whose parents consent to their involvement, with education programs at local elementary and middle schools. APMI promotes community awareness and management of asthma, particularly how to recognize environmental triggers, by educating local parents and day care, preschool and elementary school staff in Chinatown.


Children with poorly controlled asthma who are referred to the Asthma Prevention and Management Initiative by their primary care physicians or identified by APMI staff from data in the asthma registry, receive asthma action plans and tailored and culturally and linguistically competent environmental home visits and supplies, provided by the Boston Public Health Commission. APMI currently serves more than 100 families per year through the home visit program, which includes environmental assessments, medication review, review of asthma action plans and disease education for children and their families.


APMI's home visit program is part of the broader Boston Asthma Home Visit Collaborative (BAHVC). APMI draws on and contributes to the city-wide standardized approach to in-home asthma care. Where appropriate, APMI's Community Health Worker and other home visitors make referrals to Boston's Breathe Easy at Home program - an extension of the BAHVC - for housing inspection and advocacy on behalf of tenants, and refer patients to other services to reduce environmental and social stressors, as appropriate.


To complete the circle of care and ensure communication, home visitors fill out a Home Visit Progress Note and submit it to referring clinicians after each home visit. The note also is incorporated in Tufts Medical Center's ambulatory electronic medical record and listed as a patient encounter, thus enabling clinicians to review home visit findings and reinforce CHW and home visitor interventions with patients during clinical visits. As part of the BAHVC program, APMI home visitors also share de-identified home visit information with the BPHC.


APMI tracks its progress and impact in the schools, clinic and community. After four years of delivering asthma education in schools, absences for students with asthma decreased by one day, while absences for the general elementary student population decreased by only 0.2 days. Efforts to improve clinician adherence to National Institutes of Health EPR-3 Guidelines for Asthma Care also showed impressive results. Chart review data indicate that 35 percent more children, with two or more asthma-related urgent care visits within an eight-week period, now receive appropriate controller medication prescriptions than before the clinical quality improvement effort began. For children with poorly controlled asthma, APMI can demonstrate statistically significant improvements in the home environment (i.e. reduction in the presence of triggers) and asthma outcomes (i.e. improved ACT scores, decreased hospital admissions and increased use of asthma action plans) from the first to the follow-up visit, which occurs six months later.


A partnership with BPHC's Asthma program since its inception has aided APMI's sustainability. With BPHC's encouragement and the Department of Housing and Urban Development award, APMI was able to initiate its home visiting program, which Tufts MC continues to fund. APMI also is active in advocacy efforts in Massachusetts, supporting reimbursement for asthma education and home visits by third-party payers. APMI has strong data to support this case; Outcomes data from 2009-2013 show that receiving home visits decreased urgent care visits by 21 percent and inpatient admissions by six percent, saving the health care system nearly $50,000 in avoided costs.

Winnner Photo: 
Winner Photo Caption: 

From left to right: May Chin RN, Program Manager, Asthma Prevention and Management Initiative Sherry Dong, Director, Community Health Improvement Programs, Lynne Karlson MD, Division Chief, General Pediatrics and Adolescent Medicine, Sue Chin Ponte,RN NP, Director, Asian Clinical Services, Zifeng (Maple) Zou, Community Health Worker, Asthma Prevention and Management Initiative

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