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National Environmental Leadership Award in Asthma Management

Award Winners

The U.S. Environmental Protection Agency (EPA) is committed to improving the lives of people with asthma by integrating sound science into effective public health programs. In partnership with other federal agencies and nonprofit organizations, EPA delivers a national, multi-faceted education and outreach initiative to increase public awareness and action to manage environmental asthma triggers as part of comprehensive asthma management. An important component of this initiative is the recognition of exemplary programs and community leaders so that they may serve as national models and mentors for community asthma care improvement. The National Environmental Leadership Award in Asthma Management celebrates the outstanding programs and leaders who are improving the lives of people with asthma by delivering strong environmental asthma management as part of their comprehensive asthma care services.

2015 Award Winners

Le Bonheur Children’s Hospital

Le Bonheur Children’s Hospital

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.

Le Bonheur Group Photo

From L to R: Christie Michael, MD, EPA Administrator Gina McCarthy, Susan Steppe.

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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Green and Healthy Homes Initiative

The Green and Healthy Homes Initiative

The Green & Healthy Homes Initiative (GHHI) serves low-income families living in Baltimore City, Maryland, using a transformative asthma management model that combines in-home family asthma education; a comprehensive health, safety and home energy audit; and root cause remediation.

GHHI Group Photo

From L to R: Rebecca Jackson, Julian Brown, Sally Bjornholm, Mark Kravatz, Ruth Ann Norton, EPA Administrator, Gina McCarthy, Michael McKnight, Leslie Anderson, Syeetah Hampton-EL, Ezinne Chinemere.

Residents of Baltimore City, Maryland, face a higher than average rate of asthma prevalence, hospitalizations, emergency visits and deaths compared with residents of other Maryland regions and the nation as a whole. Approximately 18.6 percent of Baltimore City children have asthma, compared with the national average of only 5 to 8 percent. Furthermore, African Americans living in Baltimore are disproportionately affected. African Americans with asthma visit the emergency room 6.5 times more often than Caucasians. The asthma hospitalization rate for children in Baltimore City is twice the rate of Maryland as a whole, and African Americans in Baltimore experience an asthma mortality rate that is 3 times higher than that of Caucasians.

Working as a coalition of 35 federal, state, local, nonprofit, university and philanthropic partners, GHHI provides health-based housing intervention services to families with asthmatic children ages 2–14 who live in neighborhoods with the highest rates of asthma in the state. Homes in these very low-income communities usually are in deteriorating condition, with such environmental health hazards as high levels of dust, pest antigens, mold and very poor indoor air quality. Following the recommendations of an Environmental Assessment Technician’s report, GHHI deploys professional hazard reduction crews to remediate these home-based environmental hazards to reduce and eliminate avoidable asthmatic episodes.

GHHI began in Baltimore, Maryland, as the Coalition to End Childhood Lead Poisoning. Although originally focused on reducing lead hazards, the organization’s community-based workers perceived that other home-based environmental health hazards—especially asthma triggers—also demanded attention to support children’s health. In 2000, with seed money from the Annie E. Casey Foundation, the Coalition established one of the first Healthy Homes programs in the nation. In 2013, the Coalition changed its name to GHHI to reflect its broadened scope of services and mission impact, with Baltimore as its flagship site.

Since 2000, GHHI Baltimore has conducted housing interventions in 1,118 homes of patients diagnosed with asthma in Baltimore City. By remediating home-based environmental asthma triggers, GHHI has effectively reduced the incidence of asthma among those patients and stopped avoidable visits to the Emergency Department (ED) and hospital. GHHI’s highly successful approach served as the model for Baltimore City’s Office of Green, Healthy and Sustainable Housing. Unlike other Healthy Homes programs, GHHI integrates “green” weatherization and energy efficiency work with traditional healthy homes services, such as integrated pest management and mold removal, to achieve maximum health benefits for the target population. Moreover, GHHI Baltimore builds the community’s human capital. GHHI does this by deploying its own team of contractors to conduct multi-component home interventions and by hiring residents of at-risk Baltimore communities who receive training and accreditation to conduct interventions.

The Maryland Department of Health and Mental Hygiene’s (MDHMH) most recent data showed that, in 2009, 5,514 children in Baltimore City went to the ED for asthma, of whom 792 children who were hospitalized. Data also indicate that 52 percent of children in Baltimore who are hospitalized with asthma are residents of GHHI Baltimore’s target communities. If 52 percent of the city’s 5,514 children with asthma ED visits reside in GHHI’s target communities, GHHI Baltimore reaches approximately 4–7 percent of all children with persistent to severe asthma in those communities. To serve these children, GHHI has an intake stream from established referral sources and long-term partners, including managed care organizations (MCOs) and asthma clinics. GHHI annually serves 100–200 children diagnosed with asthma.

GHHI’s integrated, community-based approach involves all of the necessary partners to provide comprehensive care. With MDHMH funding, GHHI provides training to clinicians and staff of local community clinics and participates in Grand Rounds Trainings for physicians, pediatricians, nurses and other health care providers. GHHI reaches approximately 100 health care providers annually through the Initiative’s instruction on integrating home-based and environmental-focused intervention with comprehensive clinical care. When patients enter the program, an environmental assessment and education team meets with the family to review their home conditions. A GHHI Environmental Asthma Educator serves as the primary point of contact among the family and provider/nurse care manager/case management. The Environmental Asthma Educators staff review the patient’s Asthma Action Plan and medication management. The home asthma educators reinforce the information provided by the clinician and ensure that any behavior that may impact asthma, such as smoking, is addressed.

Besides serving clients directly, in the last 7 years, GHHI has conducted 1,743 outreach presentations and events, including 168 school presentations, 154 daycare center events, 742 community center events and 70 MCO presentations, providing more than 121,912 Baltimore City residents with information about healthy homes and asthma prevention.

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Read about the 2014 winners: Peach State Health Plan, Atlanta, Georgia; Tufts Medical Center, Boston, Massachusetts; Multnomah County Health Department, Portland Oregon.

Read Acting Assistant Administrator for Office of Air and Radiation Janet McCabe's Blog: "Recognizing Exceptional Asthma Programs", May 1, 2014.

2014 Award Winners

Peach State Health Plan

Peach State Health Plan

Peach State Health Plan in Atlanta, Georgia, is a statewide Medicaid managed care organization that delivers a customized asthma program for teenagers. The Plan is part of the Centene Corporation, an integrated health enterprise that delivers Medicaid services in 19 states. Peach State Health Plan has a targeted asthma improvement program focused on their teen members with asthma because almost 20 percent of teens in the Plan have an asthma diagnosis (13,159 members with asthma out of 66,138 members ages 13–19.) Peach State’s innovative program has successfully engaged teens with asthma—a notoriously hard group to engage—and has demonstrated success in improving teens’ ability to understand their asthma, improve their asthma, and address the environmental and social factors that can make asthma worse.

peach state group photo

From left to right - Melveta Hill-Sims, Dean Greeson, MD, Robyn Lorys, Cindy Hodnett, Virginia Bartlett, Sandra Vermillion, Stephanie Spencer, Heather Dowdy, Bruce Walters

Peach State’s Asthma Team seeks to reduce teens’ asthma healthcare utilization, improve their asthma status (i.e., functional severity), ensure appropriate medication regimens per NIH EPR-3 Asthma Program Guidelines and promote self-management. They pursue these goals by facilitating relationships between teens, caregivers, primary care physicians and medical homes, providing access to specialists, delivering tailored education and addressing social issues, such as environmental exposures at home and school.

The Plan delivers stratified asthma management services, including health coaches and environmental, medical and social interventions in clinic, at home and at school. The Asthma Team includes health plan case managers, medical directors, pharmacists, a disease manager/ health coach and respiratory health coaches, who serve as the primary contact for teens, their families, the care team and partners.

Teens with an asthma diagnosis in the Plan’s information system are stratified into three intervention groups—low, moderate and high risk—based on a multi-stage and validated initial health assessment. Sixty percent (60%) are in the low-risk intervention group and receive education materials by mail. The moderate group receives telephonic and mail outreach and can receive home visits if appropriate. The high-risk group, which includes about 700 members per year, receives telephonic and mail outreach and in-home visits. Peach State uses an innovative and award-winning incentive program, CentAccount, to motivate teens (and others) to take preventive care actions. For example, when a healthy activity, such as a preventive well visit, is completed, members receive money on a debit card they can use to purchase healthy items. This has encouraged teens with asthma to get well visits, thus helping to identify previously undiagnosed teens with asthma. In fact, teenage members in the asthma program have increased their attendance at regular wellness visits by more than 500% compared to a control group. This increased and proactive interaction with primary care providers at scheduled visits has helped teens with asthma to stay healthy and to stay ahead of their asthma rather than having them interact with their providers only after a serious asthma attack.

All teen members in Peach State’s asthma program receive award winning, age-appropriate educational materials, including the multilingual and multimedia, “Off the Chain—It’s All About Asthma” and “On Target with Your Asthma.” These materials promote understanding of asthma, environmental triggers and appropriate medication use. Members in the low-risk group receive education by mail and can also receive peak flow meters, spacers, and masks as indicated.

Members in the moderate-risk group receive mailed education materials and telephonic counseling by health coaches to identify medical, environmental and social needs and to provide asthma education and self-management support. During calls, coaches collect self-reported asthma symptom data, review individualized treatment plans and self-management guides, and discuss environmental triggers; they also teach teens signs and symptoms that merit rapid intervention. The health coaches communicate back to the medical home and cooperating community organizations, such as schools and churches.

High-risk members receive everything the moderate group receives—education, barrier assessment, coordination of care and additional support—and in-home visits by a licensed Respiratory Care Practitioner. Home visits include disease education, medication counseling and an environmental assessment, which, according to Peach State, occurs in “the ideal setting to… assess all of the factors that impact the severity of the patient’s condition…and [to facilitate] patient specific education.” During visits, health coaches conduct spirometry screening and pulse oximetry, measure vital signs, review medications, demonstrate how to use spacers and peak flow meters, and discuss barriers to effective asthma control. During home visits, teens also receive counseling from a respiratory therapist about environmental factors in the home environment and their impact on asthma to take advantage of the ‘teachable moment’ that a home visit provides. The home visit team also identifies environmental factors in the home that may be contributing to the members’ asthma and reviews in detail the teen-focused asthma education materials that address allergens and irritants.

In addition to the tailored interventions stratified by risk, Peach State’s Asthma Team also bolsters clinical providers’ abilities to care for teen asthma patients. The Asthma Team functions as an extension of the physician’s practice by reinforcing the individual asthma management plan and providing up-to-the minute documentation on functional status, barriers and recommendations for future treatment based on the assessment.

Using clinical and financial data (i.e., medical and pharmacy claims), the Plan was able to model the health improvements and cost savings generated by the teen-focused asthma program. Compared to a control group, teens in the program had nine percent fewer respiratory-related unplanned healthcare utilization incidences and a shorter average length of stay when unplanned hospitalizations did occur. They were more likely to visit their primary care physicians as planned and to receive recommended flu vaccines, a critical self-management step as people with asthma are at increased risk of severe disease and complications from the flu because influenza can cause further inflammation of the airways and lungs. Peak flow meter use and controller medication use both improved at higher rates for program participants compared to a control group, while rescue inhaler use declined, indicating better overall asthma medication management and compliance. Peach State estimates the program saves approximately $320 per member per month. Recognizing the importance of environmental management of asthma, particularly for its Medicaid population, and the impact on the quality of care and patient outcomes that their program is achieving, Peach State Health Plan, Centene and Nurtur intend to continue funding the asthma disease management program.

Tufts Medical Center

Tufts Medical Center logo

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 Asthma Award Team

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

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.


Multnomah County Health Department

Multoco.us - Multnomah County, Oregon

Multnomah County Health Department partners with organizations at the national, state and local levels to deliver a multi-component healthy homes program across Portland and Multnomah County, Oregon.

The Healthy Homes Program developed as a result of a community assessment which was guided by the efforts of a community-based environmental health coalition.  The coalition was comprised of a network of 45 community-based organizations, local agencies and public officials and was instrumental in developing and implementing a community-based environmental health assessment to identify community environmental health concerns. The goals were to identify environmental health issues, prioritize issues, develop action plans and evaluate the progress to address selected issues. 

Multonmah Group Photo

From left to right: Kim Tierney, Program Supervisor, Diane Drum RN/AAE, Jeff Strang EHS, Maria Rodas CHW, Helen Rodman RN/AAE, Gisela Garcia, Office Assistant Sr. (missing from the picture are Kari Lyons, Policy Analyst, and Lila Wickham, former Environmental Health Director)

The assessment data and results became the impetus for developing the Healthy Homes Asthma program and focusing on improving indoor air quality and reducing asthma triggers in the homes of low income families with children with asthma. The Multnomah County Environmental Health Services (MCEHS) sponsored the Healthy Homes Coalition, which emerged from the Summit with a goal to address environmental factors that affect asthma and other health conditions by prioritizing substandard housing and housing codes.

The work of the coalition resulted in the successful submission of a grant to the Department of Housing and Urban Development (HUD) Healthy Homes program in 2005.   With HUD funding, MCEHS began delivering in-home nursing case management, environmental assessments, behavioral interventions and supplies to reduce asthma triggers for low-income families of children with asthma. In addition to direct care services, the program also focused on policy development, housing code enforcement, integration with clinical providers, and connections to remediation and community support resources.

MCEHS initially developed the Healthy Homes Program for low-income children with asthma who received primary care at county health department clinics.  In 2009, MCEHS developed an Asthma Inspection and Referral (AIR) program, a one-time home inspection program for any child with asthma, regardless of income.  AIR augmented the more in-depth Healthy Homes program, which targeted low income and less controlled children with asthma.  Over time, the Healthy Homes Program broadened its services, developing the Community Asthma Inspection and Referral (CAIR) program funded by a HUD Demonstration Grant, to deliver home assessments to an even broader group of children with asthma and other environmentally related health conditions. Referrals to the Multnomah County Asthma programs now come from clinic providers and other community organizations throughout Multnomah County.   Through a web based referral system the programs were able to accept referrals from community medical providers, community based organizations and other partners through-out the county. MCEHS and its growing group of partners continued to expand the services and reach of the Healthy Homes to include Healthy Homes, AIR, and CAIR.  Working in collaboration with other community partners such as the City of Portland, they seek to address asthma at the individual, family, organizational, community and public policy levels to improve outcomes for all children in the county.

Multnomah County Health  Department logo

MCEHS’ Healthy Homes program is available to low-income families and prioritizes children with uncontrolled asthma who have had recent ER visits, or who are prescribed inhaled corticosteroids. Healthy Homes positions a Community Health Nurse (CHN) as the child’s case manager and a Community Health Worker (CHW) to help manage the home environment. Together, they conduct approximately seven home visits and provide ongoing telephone support. CHNs receive referrals, review cases and consult with providers. During home visits, CHNs focus on assessing asthma severity and control, reviewing medication, and developing individualized asthma care plans. CHWs work with families on environmental assessments and interventions. Both CHWs and CHNs link families to support resources; CHNs link to medical services and consult with the medical team and pharmacy, while CHWs connect families to remediation and other services.

Over approximately six months, Healthy Homes program CHWs provide customized assistance in implementing the Family Action Plan. Assistance consists of in-home and telephone support, education ,behavioral interventions, skill-building demonstrations and providing supplies, such as green cleaning kits, vacuum cleaners with HEPA filters, allergen-free bedding encasements, door mats, bed frames  and linens. In addition, families may be given basic maintenance items such as batteries for smoke detectors, furnace filters or new smoke detectors. Client assistance items average $336 per family.

With the expansion of the initiative to add CAIR, providers and social service agencies began to use a Web-based system for referrals, charting, and reporting. In AIR an Environmental Health Specialist (EHS), performs a single environmental assessment. If appropriate, he might refer clients directly into Healthy Homes or CAIR. CAIR program staff included two CHWs who served as case managers. They conducted environmental assessments, basic interventions, addressed behaviors and make referrals. Physical and structural remediation concerns were referred to the EHS who was able to leverage services for home repair.  Uncontrolled health issues were referred to the CAIR CHN.

The Healthy Homes program has collected outcomes data since 2005, and the CAIR program has collected data since its inception in 2010. Both Healthy Homes and CAIR programs tracked environmental assessment scores, asthma control test (ACT) scores and ER visits.

The Healthy Homes program has demonstrated a 2.5 times reduction in the use of ER and significant reduction in hospitalizations for children with asthma who have completed the program. In addition, the Healthy Homes intervention is associated with a statistically significant reduction in the number of environmental observations of asthma triggers in both Healthy Homes and CAIR. Finally, 75 percent of Healthy Homes’ clients showed improved ACT scores over a six month period. Based on a 2008 evaluation conducted in partnership with Care Oregon, the managed care plan that served 99 percent of Healthy Homes’ participants at the time of the evaluation, the program resulted in almost $350,000 in savings from avoided health care utilization (i.e., avoided hospitalizations and ED visits).

To sustain the program, MCEHS advocated for direct reimbursement from the State of Oregon.  In 2010 MCEHS negotiated with Oregon Department of Medical Assistance Programs and Center for Medicaid  Services, CMS to develop  Healthy Homes targeted case management, allowing for Medicaid reimbursement. In addition, the Healthy Homes Coalition continues to seek to embed environmental solutions for asthma in the housing code, improve substandard housing and advocate for tenants.

2013 Award Winners

Health Care Provider Winners

Communities in Action Winner

Greenville Health System's Asthma Action Team, Greenville, SC

The Center for Pediatric Medicine (CPM) Asthma Action Team (AAT) within the Greenville Health System Children's Hospital is the major clinical provider of outpatient care for children with limited health care access in Greenville, South Carolina. A diverse community, Greenville is South Carolina's most populous county and asthma/bronchitis is the leading cause of hospitalization for children under 18 in the area. Ninety percent of the population served at CPM receives Medicaid funding.

Greenville Health System's Asthma Action Team

[Pictured left of sign] l-r: Tom Moran, Jane Teague, Karla Mora, Dr. Josh Henry, Dr. Andrew Wilt, Katy Smathers, Tiffany Timms
[Pictured right of sign] l-r: Dr. April Buchanan, Dr. Jill Golden, Dr. Lochrane Grant, Joann Wilson, Rita Rivera, Kristi Caballero, Cindy Garnett, Dr. Amanda O'Kelly, Dr. Cari Sanders, Cheryl Kimble, Debra Powers, Pam Kruzan, Dr. Elizabeth Shirley

The AAT is a multidisciplinary, multilingual, family-centered program within CPM that was formed in 2008 to address increasing asthma prevalence, increasing pediatric emergency department (ED) visits and hospitalizations and ED recidivism for asthma, and growing asthma disparities in greater Greenville. The AAT is staffed by pediatricians, certified asthma educators, respiratory therapists, case managers, nurses, social workers, translators, an electronic medical record (EMR) technician, and community home visitors. Residents training in pediatrics, internal medicine, family practice and third and fourth year medical students also rotate through the AAT clinic where they learn an evidence-based approach to asthma care according to the National Asthma Education and Prevention Program (NAEPP) Guidelines for the Diagnosis and Management of Asthma.

The program strives to ensure that patients and families receive consistent asthma education and support services in clinics, homes, schools and daycares, including support for environmental asthma control, in order to promote effective self-management and avoid emergency health care utilization. The AAT coordinates with payers, local schools, community-based organizations and others to identify patients in need and to provide case management for children and adolescents with hard to control asthma. Case management includes asthma education, home visits, office visit coordination and school visits with a certified asthma educator from CPM serving as the case manager.

All AAT patients receive personalized pictorial asthma action plans written in their primary language which AAT staff review and update at every patient interaction and share with providers across the Greenville Health System (GHS) network and with school and daycare providers. The action plans are stored in the patients' EMR and on a web-based platform where clinical providers and educators working across both inpatient and outpatient settings can access and update them. The AAT also maintains a registry and alert system to help manage 4,338 pediatric patients with asthma, to track their asthma outcomes in real time, to stratify patients for care and to ensure high quality and appropriate care is consistently delivered.

The AAT focuses on delivering comprehensive and guidelines-based clinical and environmental care everywhere people with asthma spend time. The team is acutely aware of the social, economic and cultural factors that affect pediatric asthma outcomes for the diverse community GHS serves. To help children with asthma and their family's access to appropriate clinical care and avoid emergency health care use, CPM offers extended evening and weekend hours, same day service to children experiencing asthma exacerbations, and an after-hours telephone triage line. The AAT also partners extensively to provide education, diagnostics, in-home services and social supports for environmental interventions in the community. Partners include the Family Connection of South Carolina's Project Breathe Easy (PBE), the South Carolina Asthma Alliance, the Greenville Pediatric Asthma Community Collaborative, the Greenville County Schools and many others. This network of partners allows the AAT to provide personalized environmental counseling in the clinic, environmental home visits and asthma education that includes environmental counseling in the community, and at school and day care sites.

Perhaps the strongest evidence of the AAT's impact is the fact that at the same time that the population of children with asthma in the CPM system grew by an annual rate of 63 percent, rates of ED visits for asthma declined. Data from the AAT's partnership with PBE — which applies only to AAT clients who receive referrals to PBE — demonstrate a 71 percent decrease in urgent health care utilization, a 21 percent decrease in unscheduled clinical care visits, a 51 percent decrease in missed school days, and a 41 percent decrease in missed work days for parents post intervention.

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Parkview Health System, Fort Wayne, IN

Parkview Health System

Parkview Health System is a nonprofit health care provider that delivers care to more than 875,000 people in a five county area in northeast Indiana. Parkview's community consists of urban, suburban and rural populations that have seen increasing asthma prevalence over the past 15 years. In response to rising asthma rates, data indicating that asthma is a major health concern and a frequent cause for emergency health care services, particularly among low-income communities served by Parkview, and input from community partners, the hospital developed a comprehensive Asthma Education and Management Program in 2004.

Parkview Health System, Fort Wayne, IN

Pictured l-r: Deb Lulling and Jan Moore

Parkview's Asthma Education and Management Program identifies children and adults with asthma in order to improve their ability to self-manage by providing support services, resources and age-appropriate education. The program is run by the hospital's Integrated Community Nursing Program and relies on Parkview's partnerships with local school districts and social service agencies to enroll patients and deliver Program services. Parkview also partners with the Fort Wayne-Allen County Department of Health and Indiana State Department of Health (ISDH) to provide environmental home visits and to evaluate the Asthma Education and Management Program's impact. With its partners, Parkview reaches people each year with asthma education, including school nurses, teachers, coaches, bus drivers and other school staff. Parkview also works with the County's Healthy Homes Program to provide environmental home visits and in-home asthma/allergy education.

The second program component is the Emergency Department (ED) Asthma Call Back Program, which began in 2009, and serves over 1200 individuals on an annual basis. The Call Back Program equips people who have visited the ED for asthma care with the knowledge and tools they need to manage their asthma and avoid future ED visits. All patients who visit the ED for asthma-related illnesses receive calls from an asthma educator after they are discharged to discuss asthma control, and access to and use of appropriate medications. Where indicated, nurses can order home visits to provide environmental asthma trigger assessment and mitigation. Home visitors typically provide supplies, including bedding encasements, HEPA vacuums and green cleaning supplies at no-cost, and provide asthma education. Qualified patients who cannot afford their asthma medications or do not have a medical home are enrolled in Parkview's Medication Assistance Program and referred to a physician in the Parkview system, a Federally Qualified Health Clinic, or a free clinic.

Through its partnership with ISDH, Parkview has access to evaluation data that demonstrate the impact of its asthma program. Surveillance data show improved asthma outcomes over time in counties served by Parkview as compared to demographically similar counties within the state. ISDH's evaluation of the ED Call Back Program found that it is effective at reducing ED readmissions: ED recidivism dropped to 15.04 percent in the intervention group compared to 21.95 percent in the control group. The ED Asthma Call Back Program also demonstrated impact on school and work attendance and quality of life with nearly 59 percent of participants reporting they had missed zero school or work days since involvement in the program. The program has also demonstrated a positive impact on increasing access to medical homes and controller medication with 11.2 percent of participants acting on physician referrals and 16.4 percent receiving prescription support services. Finally, Parkview's own data demonstrate a reduction in inpatient visits for asthma over time and reduced average costs per patient encounter. Parkview has been able to demonstrate a steadily improving return on investment (ROI) from the ED Asthma Call Back Program — from $20 saved for every $1 invested in the baseline year to $23.75 saved per dollar invested in 2012. This ROI data helped Parkview's leadership decide to expand the ED Asthma Call Back Program to all six campuses within the health system.

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North East Independent School District, San Antonio, TX

North East Independent School District

The North East Independent School District (NEISD) is a large urban district that serves 67,000 students, including more than 8,000 with asthma. In 2006, NEISD hired a Registered Respiratory Therapist/Certified Asthma Educator (RRT/AE-C ) to launch an asthma management program to improve students' asthma control and school attendance in order to positively contribute to the district's academic performance.

NEISD's investment in the Asthma Awareness Education Program (AAEP) reflects its leadership's recognition that asthma control is fundamental to student achievement.

North East Independent School District

[Pictured front row] l-r: Diane Rhodes and Kathy Hardin
[Pictured back row] l-r: Girish Nair, Larry Fowler, Nick Kellar
In cooperation with campus nurses, custodial staff, PE teachers, administrators and district facility maintenance staff.

The AAEP's evaluation data have confirmed the link and demonstrated that comprehensive school-based asthma management programs can reduce symptoms, improve disease management, reduce emergency health care utilization, increase school attendance, thus impacted academic performance and generate a return on investment. In Texas, as in a handful of other states, average daily attendance rates are at the foundation of the state's formula for distributing school revenue. An effective school-based asthma control program like NEISD's can quickly increase attendance and thereby pay for itself.

The AAEP provides education, disease management tools, and other supports to help school nurses identify and monitor students with asthma, and improve communication between schools and clinical staff. NEISD also provides case management services for children with hard to control asthma, including RT/AE-C-led home visits, personalized counseling and coordination with asthma specialists. The Asthma Blow Out (ABO) is the AAEP's community engagement component, which is delivered in areas with the largest disparities in asthma outcomes. The ABO brings RT/AE-Cs and physician partners to local schools where they provide disease management strategies and medication counseling, provide access to flu vaccines and provide age-appropriate asthma education to students, parents and others. To decrease healthcare barriers where indicated NEISD provides bus transportation to and from the schools, free meals, English-Spanish translation services and offers academic incentives for students to attend the ABO events.

The AAEP addresses environmental asthma triggers in schools through training for custodial staff, monthly meetings with facilities staff, training for principals and teachers, an asthma management component in the high school's Healthy Lifestyles course, an air quality health alert policy to ensure the campus community knows when unhealthy outdoor air conditions occur and regular monitoring of asthma symptoms and possible environmental exposures in schools. The AAEP also promotes environmental asthma management at home.

In the six and a half years since the program's launch, the AAEP has reduced asthma symptoms in school as measured by declines in rescue/reliever medication use — for example, inhaler use declined by 50 percent during the first six weeks of school from the first year to the next and when targeted campus environmental strategies took place; and reduced emergency medical service transports during the school day from 80 transports per year to 24 transports per year. The AAEP has delivered asthma education to every district campus, by reaching every physical education teacher, nurse and campus administrator. ABO survey results also demonstrate improved student and parent understanding of appropriate asthma management strategies — 95 percent of parent attendees surveyed said they would recommend the ABO program to a friend. And the district has seen yearly attendance averages increase from 95.3 percent to 96.1 percent since the AAEP's inception, including significant increases during flu season. NEISD has achieved state-recognition as a Recognized District for its academic performance four years in a row. There is widespread agreement that the AAEP-led environmental improvements and involvement in student health contributed to improved student performance and the district's academic accomplishments.

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2012 Award Winners

Health Plan

L.A. Care Health Plan

L.A. Care Health Plan
L.A. Care Health Plan established the comprehensive disease management program LA Cares About Asthma® in 2003. L.A. Care selected asthma as a disease management focus because of the large number of members with asthma enrolled in L.A. Care and the success of programs like these in helping patients with chronic illness improve their health status over the course of the disease. LA Cares About Asthma® is a collaborative program designed to improve member self-management through education, empowerment, monitoring and member input and communication.

L.A. Care Health Plan

Pictured l-r: Johanna Aceves, Johanna Kichaven, Rachel Martinez, Joanne Wei, Melissa Diaz, Hela Mahgerefteh, Laura Linebach, Lisa Diaz, and Devaki Magee.

On a monthly basis, LA Cares About Asthma® identifies health plan members with asthma and provides them with a variety of educational materials and tools to help them take control and manage their disease. To be inclusive to its community's needs, the program ensures that linguistically and culturally appropriate materials are available for all potential enrollees.

LA Cares About Asthma® also partners with several community-based organizations to expand its reach and depth to serve individuals most in-need. An in-home visitation program with Long Beach Alliance for Children with Asthma in the Los Angeles South Bay area and specialist referrals with Harbor-UCLA Medical foundation Inc., throughout Los Angeles County offered to high-risk members with asthma are just two examples of such successful partnerships.

Thanks to these efforts, LA Cares About Asthma® achieved a member satisfaction of 97.6 percent, which exceeded their 2011 goal. In particular, members reported great satisfaction with the program materials and felt the materials educated them on how to control their asthma.

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Health Care Provider

Mission Children's Hospital

Mission Children's Hospital
Mission Children's Hospital serves the 21 most rural and isolated counties in North Carolina. This area's diverse minority population faces some of the greatest health disparities in the state, and further, the majority of Mission Children's Hospital patients are uninsured or underinsured. Pediatric asthma, unsurprisingly, is one of these disparate health concerns.

The Regional Asthma Disease Management Program at Mission Children's Hospital

Pictured l-r: Don Russell, M.D., Supervising Physician; Shawn Henderson, Practice Manager, Mission Children's Hospital; Melinda Shuler, Regional Clinical Coordinator/ Principal Investigator; Amy Trees, Case Manager; Helen Thingvoll, Office Specialist

Through an innovative and bold approach designed to meet the unique needs of this population and to impact minority children suffering from asthma in a significant way, Mission Hospital developed the Regional Asthma Disease Management Program (RADMP).

RADMP confronts these issues at the root of the problem — taking the clinical approach to asthma management and control into non-clinical settings, such as homes, schools and other care facilities in outlying areas. The program addresses social determinants of health, medical and environmental management, education on asthma and environmental triggers, and comprehensive care through an ever-expanding network of invested stakeholders and agencies.

In order to reach minority and low-literacy populations, RADMP utilizes population specific outreach materials and interpretive services. For low-income families, the program offers access through Mission's Medication Assistance Program for asthma medications. Home remediation to eliminate environmental exposures is provided through RADMP's strong network of community partners.

In 2008, the program was recognized as one of the state's top three asthma disease management programs. In 2009, RADMP received a two-year demonstration project grant from the National Heart, Lung, and Blood Institute (NHLBI), as part of the National Asthma Control Initiative. Since 2009, RADMP activities have contributed to reducing asthma-related emergency room visits by 94 percent and hospitalizations by 95 percent, equaling a total savings of more than $800,000. In addition, the average number of school days missed by children in the program decreased from 17 to nine, indicating an increased quality of life. Statistically significant improvements were made in clinical measures including lung spirometry and eosinophilic inflammation.

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Community in Action

Connecticut Children's Medical Center

Connecticut Children's Medical Center
In 1998, the city of Hartford, Connecticut had a growing population of low-income minority citizens with asthma. Only one-third of children with persistent asthma in this community were being treated with appropriate anti-inflammatory medication, and most of these children lived in old housing where pest infestation and overcrowding were common problems.

The community needed a cost effective asthma management program to assist busy primary care clinicians in diagnosing asthma and effectively treating patients. The result was the creation of the Easy Breathing© program.

Easy Breathing© — originally housed within the Connecticut Children's Medical Center — focuses on five elements of care: diagnosing asthma, determining asthma severity, prescribing therapy appropriate for the asthma severity, developing a written Asthma Treatment Plan that is understood by the family, and assessing asthma control.

Connecticut Children's Medical Center

Michelle M. Cloutier, MD, the Program Director of Easy Breathing at Connecticut Children's Medical Center.

The program then utilizes a database to track its outcomes, including environmental exposures, interventions and feedback for clinicians. The database is also used for research and reporting purposes, and it provides clinicians with information regarding the demographics of their patient population, environmental exposures and asthma severities for all children enrolled in the program.

An essential element of the program is the Easy Breathing© Survey, which is administered in the physician's office when the patient comes for an office visit. The survey helps parents identify environmental exposures in the home that are potentially problematic for a child with asthma. The results of the survey are then immediately discussed with the patient and are used as a starting point for education regarding avoidance and elimination of harmful environmental conditions, such as smoking in the home.

Today more than 106,000 children across the state have been enrolled in the Easy Breathing© program — more than 28,000 of which have asthma. This success is due in large part to extensive community partnerships between clinicians, parents, hospitals, clinics, schools, foundations, lung associations, housing authorities and pharmaceutical industry representatives that have been a cornerstone of the program from its inception.

Easy Breathing© has been tremendously successful and has lead to significant increases in the use of written treatment plans, decreases in hospitalization rates and emergency department visits for asthma, and increased usage of inhaled corticosteroids. The program is now being implemented throughout Connecticut and in nine other states.

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Michigan Department of Community Health

Michigan Department of Community Health
In the mid-90s, the Michigan Department of Community Health (MDCH) recognized asthma as a growing health problem, especially among low-income children and populations with economic, race and access disparities. As MDCH geared up to increase asthma awareness in these disproportionately affected communities, it quickly determined that a coordinated effort would ultimately have the greatest impact on health outcomes.

Therefore, in 2000, MDCH brought together more than 125 asthma experts to develop the first statewide plan to address asthma in communities bearing the highest burden. This successful collaboration lead to the creation of the Asthma Prevention and Control Program (APCP).

Michigan Department of Community Health

[Front row] l-r: Evelyn Gladney, Erika Garcia, Tisa Vorce, John Dowling [Back row] l-r: Bob Wahl, Judi Lyles, Sarah Lyon-Callo, Bill Baugh

The APCP, which provides expertise and long-term guidance for asthma quality improvement activities, has aided in the development and impact of many successful community-based asthma management programs across the state, such as Managing Asthma Through Case-management in Homes (MATCH). This program utilizes a combination of home, school and work visits; asthma action plans; and Medicaid reimbursement to provide long-term interventions and care for individuals with asthma. MATCH participants reported significantly fewer emergency room visits and hospitalizations, and had significantly shorter lengths of stay, if hospitalized due to asthma.

Recognizing the success of the program, APCP helped to replicate this model in other communities, and as a result, has more than doubled the number of people served by MATCH. Surveillance data and input from strategic partners have been key components to this success and are used to continuously measure both the state's and community's needs and to ensure that any changes in asthma burden result in adjusted programming.

Between 2000 and 2007, APCP's efforts have contributed to a 24 percent reduction in the asthma mortality rate in Michigan, preventing an estimated 182 deaths. Similarly, pediatric asthma hospitalization rates in the state decreased by 28 percent between 2000 and 2009. In addition, children enrolled in Michigan Medicaid programs exhibited a 41 percent decrease in asthma hospitalizations between 2005 and 2009.

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2011 Award Winners

Centene Corporation® Managed Health Services, Nurtur®
(St. Louis, Missouri and Indianapolis, Indiana)

Centene Corporation
As an experienced, comprehensive service provider, Managed Health Services, a Centene Corporation Medicaid health plan, understands the need to customize asthma solutions for diverse populations. As a result, in 2007 Managed Health Services and sister company, Nurtur, Centene life, a health and wellness company, established a comprehensive asthma program designed to address the needs of several specific target audiences; these include persons with asthma in addition to other complex chronic conditions, as well as pregnant women and children with asthma.

Centene Corporation® Managed Health Services Nurtur®

Pictured: Mike Flynn, Director, Office of Radiation and Indoor Air and Gina McCarthy, then Assistant Administrator, Office of Air and Radiation, U.S. EPA, present Award to Patrick Rooney, Dr. Mary Mason and Dan Cave of Managed Health Services, Centene Corporation ® and Nurtur ®.
Click on the image for a larger version

Medical records, pharmacy records and claims data are scanned by predictive modeling software to identify patients that meet these criteria, who are then referred to the Asthma Team. A case manager follows up with each patient to assess their level of need and recommends an appropriate asthma intervention. Educational materials for children and adults, trigger identification training, goal-setting exercises, home visits and barrier assessments are just some of the many tools used as a part of this holistic asthma care process. The patient's treatment plan is also updated by the Asthma Team and sent to the physician for review. Continuous monitoring and evaluation are integral to this program, and results from 2007 to 2009 indicate an incredible 17.3 percent decrease in emergency department visits for child participants and a 9.4 percent decrease for adult participants. In addition, visits to primary physicians for children and adults were up by 11.1 percent and 16.4 percent, respectively, indicating improved preventive care.

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South Bronx Asthma Partnership, Bronx-Lebanon Hospital Center
(Bronx, New York)

South Bronx Asthma Partnership
In New York's South Bronx community, one in five school-aged children has asthma — one of the highest rates in New York City. In response to this staggering statistic, Bronx-Lebanon Hospital Center's Department of Pediatrics created the Childhood Asthma Management Program in 2000. Through clinical pediatric asthma services, community-based activities of the New York State Department of Health-funded asthma coalition, and hospital-community collaborative programming, the program promotes asthma-friendly environments and ensures the delivery of integrated health care services for children with asthma.

South Bronx Asthma Partnership, Bronx-Lebanon Hospital Center

Pictured: Mike Flynn, Director, Office of Radiation and Indoor Air and Gina McCarthy, then Assistant Administrator, Office of Air and Radiation, U.S. EPA, present Award to Lauren Brown, Alexandra Meis, Dr. Mamta Reddy, Tomas Jimenez, Diane Strom and Evelyn Arguinzoni of the South Bronx Asthma Partnership, Bronx-Lebanon Hospital Center.
Click on the image for a larger version

Early on, program staff members recognized that to improve asthma outcomes, they must not only improve provider knowledge and communication, but also strengthen the existing health system in which providers practice. As a result, the program conducts provider training sessions that translate asthma management recommendations into quality clinical practice to ensure that patients receive comprehensive asthma services across the care continuum. Furthermore, the program engages Medicaid to provide reimbursement incentives for provider participation in asthma education.

As the lead organization of the South Bronx Asthma Partnership, Bronx-Lebanon Hospital Center also partners with a variety of environmental agencies and community organizations to create tailored environmental interventions that address both indoor and outdoor asthma triggers. Program partners provide building walk-throughs, designate asthma-friendly zones at schools, and provide pest management assistance and air-sampling. In addition, the program distributes culturally appropriate and literacy-sensitive educational materials throughout the hospital and the community to promote patient self-management and encourage healthy behaviors in homes.

This multi-faceted approach to asthma care has resulted in tremendous success. Since 2003, Bronx-Lebanon Hospital Center has shown a 42 percent decrease in asthma-related hospitalizations, as well as a decrease in the length of stay of asthma-related hospitalizations. This equates to an annual average cost savings of about $431 per child. In addition, the National Asthma Control Initiative recently named the Bronx Lebanon partnership as a clinical champion in recognition of their efforts in promoting the Expert Panel Report 3 — Guidelines for the Diagnosis and Management of Asthma.

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New York State Department of Health, Center for Environmental Health, Healthy Neighborhoods Program
(Troy, New York)

Healthy Neighborhoods Program
In the early 1980s, the New York State Department of Health, Center for Environmental Health recognized that housing hazards were often complex and were best addressed by a neighborhood-level approach. As a result, the Center developed the Healthy Neighborhoods Program in 1985 — a statewide program aimed at improving housing conditions in high-risk communities through a holistic, healthy homes approach.

Pictured: Mike Flynn, Director, Office of Radiation and Indoor Air and Gina McCarthy, then Assistant Administrator, Office of Air and Radiation, U.S. EPA, present Award to Amanda Reddy and Theresa McCabe of the New York State Department of Health, Center for Environmental Health, Healthy Neighborhoods Program.
Click on the image for a larger version

This program relies on an extensive network of grant-funded, local health department partners and emphasizes home environmental management as an enhancement to case management and clinical care. Local health departments initially identify target areas in the community for intervention and develop work plans to meet the specific needs of that area. These health departments are also encouraged to leverage local resources and infrastructure to ensure that the services delivered are meaningful and effective.

During home visits, field staff members assess a wide variety of healthy homes issues, including tobacco control, fire safety, lead poisoning prevention, indoor air quality, asthma control, injury prevention and more. Following the assessment, residents are provided with products, referrals and education to help remediate any potential hazards identified during the assessment. A quarter of homes receive a three-to-six month follow-up visit to reassess conditions. Any new or ongoing problems identified during the revisit are addressed.

This program has had incredible success for residents with asthma, with marked improvements in environmental triggers, including a 14% reduction in environmental tobacco smoke exposure and improved pest control in at least 44% of homes with pest problems. There have also been significant improvements in participants' knowledge about asthma triggers and significant decreases in the number of days with worsening asthma and in the number of work or school days missed due to asthma.

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2010 Winners

Community Asthma Initiative, Children's Hospital Boston

Community Asthma Initiative, Children's Hospital Boston logo
Childrens Hospital Boston

Gina McCarthy, then Assistant Administrator, Office of Air and Radiation, U.S. EPA, and Mike Flynn, Director, Office of Radiation and Indoor Air, U.S. EPA, present Award to (from left to right) Susan Sommer and Dr. Elizabeth Woods of the Community Asthma Initiative, Children's Hospital Boston

Children’s Hospital Boston developed the Community Asthma Initiative (CAI) in 2005 in response to alarmingly high rates of asthma among children living in Boston’s urban neighborhoods, especially underserved children and families. CAI is a patient-centered program that provides bilingual (Spanish) in-home family asthma education, environmental assessments and remediation; Integrated Pest Management; and coordination with primary care providers, in conjunction with community education, outreach and advocacy. Care is provided and coordinated through a culturally appropriate case management model that identifies barriers to good asthma control and includes home visits conducted by nurses and/or community health workers, depending on the family’s needs. To ensure it provides the services and information the community needs most, CAI convenes a Family Advisory Board. In response to the Family Advisory Board’s vision, CAI delivered an Asthma Community Forum, with over 100 attendees discussing asthma-related issues, including environmental management in homes and schools. CAI also offers educational programs and activities for community-based organizations, schools and provider groups. For example, CAI, along with the Boston Public Health Commission (BPHC), hosts the Boston Asthma Swim Program, which provides children with asthma the opportunity to engage in physical activities while learning about asthma control. To improve insurance coverage for case management and home visits — and to increase access to affordable medications and reimbursements — CAI works closely with the Office of Government Relations at Children’s Hospital Boston, BPHC and community partners, providing support for policy and system changes. The Initiative has achieved impressive results. For CAI patients, asthma-related emergency department visits have dropped by 65 percent and hospitalizations have decreased by 81 percent. Further, CAI calculated a 146 percent return on investment (ROI) to society due to lower hospital costs. Enrolled families have also reported a reduction in the limitation of physical activity (37 percent), asthma-related school absences (39 percent), and asthma-related work absences (49 percent).

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Neighborhood Health Plan of Massachusetts

Neighborhood Health Plan of Massachusetts logo
Neighborhood Health Plan

Gina McCarthy, then Assistant Administrator, Office of Air and Radiation, U.S. EPA, and Mike Flynn, Director, Office of Radiation and Indoor Air, U.S. EPA, present Award to (from left to right) John Pruett, Joy Gonzalez, Dr. James Glauber and Cindy Cookson of the Neighborhood Health Plan of Massachusetts

Founded in the late 1980s, Neighborhood Health Plan (NHP) was one of the nation’s first health plans to comprehensively address the health care needs of underserved populations. As part of its commitment to improving the lives of its 200,000 members and in response to alarming rates of asthma among the Plan’s target population, NHP introduced its innovative Asthma Disease Management Program (ADMP) in 2000. NHP provides an Asthma Home Visitation Program (AHVP) to all members living with asthma in need of in-depth asthma education and/or home environmental assessment. NHP implemented an Enhanced Asthma Home Visit program in 2005 based on the positive outcomes of a one year Inner City Asthma Study (ICAS) of non-clinician home-based environmental intervention to reduce exposure to environmental triggers and allergens. The AHVP empowers patients to proactively manage their asthma by providing multilingual, low-literacy education to patients and their families during in-home environmental assessments and interventions. In addition, the ADMP helps primary care providers improve asthma care by enhancing programs at primary care sites; using a robust and comprehensive asthma registry; and increasing provider awareness and compliance with asthma treatment guidelines. To further address the appropriate management of asthma, NHP’s website provides access to several provider-focused resources. By collaborating with community-based initiatives, including the Boston Asthma Initiative, the Greater Brockton Asthma Coalition, and State and regional partners, the ADMP’s active leadership strengthens Massachusetts’ community-wide approach to asthma management. Over the past decade, the rates of annual asthma hospitalizations and emergency department visits for Neighborhood Health Plan’s asthma population have fallen by more than 30 percent.

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Sinai Urban Health Institute

Sinai Urban Health Institute logo
Sinai Urban Health Institute

Gina McCarthy, then Assistant Administrator, Office of Air and Radiation, U.S. EPA, and Mike Flynn, Director, Office of Radiation and Indoor Air, U.S. EPA, present Award to (from left to right) Gloria Seals, Helen Margellos-Anast and Melissa A. Gutierrez of the Sinai Urban Health Institute

Since 2000, the Sinai Urban Health Institute (SUHI) and Sinai Children’s Hospital (SCH) have partnered to reduce the burden of asthma on vulnerable Chicago communities. As many as one in four children living in the communities served by the Sinai Health System suffer from asthma, as revealed by the Sinai Improving Community Health Survey. Recognizing the disproportionate asthma burden faced by these communities, a series of four comprehensive asthma interventions have been conducted over the past 10 years. Each of these initiatives has focused on decreasing asthma-related morbidity and improving participants’ quality of life by utilizing Community Health Workers (CHW)—members of the community trained to deliver case-specific asthma education through home visits. With funding from the U.S. Centers for Disease Control and Prevention, SUHI and SCH initiated a comprehensive, multifaceted program in September 2008, called Healthy Home, Healthy Child: The Westside Children’s Asthma Partnership (HHHC). This unique program draws from the strengths of its collaborations with partner organizations and community members to address medical, social and environmental factors of asthma. At the heart of this program is the CHW, who provides one-on-one asthma education and environmental trigger reduction counseling to families in their homes. The CHWs also serve as a liaison between the family and medical system. Cost savings analyses and evaluations of these programs have enabled SUHI to demonstrate the approach’s value, proving that the program was a wise investment. Since the inception of the SUHI Pediatric Asthma Programs, there has been on average a 50 percent reduction in frequency of symptoms experienced by children (50.4 percent – 63.6 percent) and significant declines in asthma-related emergency department visits (47.6 percent – 73.5 percent) and hospitalizations (50.0 percent – 81.0 percent). In addition, the SUHI Pediatric Asthma Model has been replicated in other areas around Illinois.

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WIN for Asthma

WIN for Asthma logo
Win for Asthma

Gina McCarthy, then Assistant Administrator, Office of Air and Radiation, U.S. EPA, and Mike Flynn, Director, Office of Radiation and Indoor Air, U.S. EPA, present Award to (from left to right) Robyn Scherer, Patricia Peretz and Dr. Luz Adriana Matiz of WIN for Asthma

In 2005, New York Presbyterian Hospital and community partners applied the principles of community based participatory research to develop the Washington Heights Inwood Network (WIN) for Asthma. This comprehensive program is designed to facilitate effective and sustainable asthma management in Northern Manhattan, a community with childhood asthma rates that are four times the national average. WIN is a multi-level, community-driven program that enhances case identification and follow-up for children. Through collaboration with key partners, including local day care centers, schools, clinics and community-based organizations, WIN provides community-wide asthma screening and education. Once families are enrolled in the program, bilingual community health workers offer family-focused asthma education, address household triggers, and link families to the clinical and social resources needed to facilitate effective and sustainable asthma management. By engaging and supporting local providers through the delivery of the evidence-based intervention, Physician Asthma Care Education (PACE), WIN works to ensure providers adhere to the latest asthma guidelines, resulting in improved quality of care. Through a partnership with the National Initiative for Children’s Healthcare Quality, WIN developed a comprehensive protocol for post-PACE provider support involving practice-based support. Through collaboration with multiple hospital divisions, the launch of a grassroots marketing campaign, and the development of a long-term business plan, WIN has worked to increase its visibility and successfully sustain its program. WIN’s program success is demonstrated in data collected from Community Health Workers (CHWs): Over a 3-year period, the number of asthma-related emergency department visits and hospitalizations decreased by more than 50 percent; caregivers’ confidence in controlling their children’s asthma increased by 40 percent; and asthma-related school absenteeism decreased by 30 percent.

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Woodhull Medical and Mental Health Center

Woodhull Medical and Mental Health Center logo
Woodhull Medical

Gina McCarthy, then Assistant Administrator, Office of Air and Radiation, U.S. EPA, and Mike Flynn, Director, Office of Radiation and Indoor Air, U.S. EPA, present Award to (from left to right) Dr. Edward Fishkin and Desire La Tempa of the Woodhull Medical and Mental Health Center

Twelve years ago, the Woodhull North Brooklyn Health Network implemented its comprehensive, evidence-based asthma management program to ensure best practices for asthma care were used to treat all asthma patients. By educating and training health care providers, community organizations and schools, Woodhull has taken a multi-faceted approach to improving asthma care in one of the nation’s highest-risk communities for asthma. At the center of this approach is the Network’s leadership in heading the North Brooklyn Asthma Action Alliance, a coalition that partners with national organizations, community groups and health care facilities to deliver a high standard of asthma care to the community. Supporting this work, the program trains doctors, nurses and hospital residents with its PACE program, which aligns with the National Institutes of Health Guidelines for Asthma Care, and utilizes a modified Electronic Health Record to ensure that all of Woodhull’s providers deliver Guidelines-based care. In partnership with Rutgers University, Woodhull performs ground-breaking education on environmental triggers to schools, including the distribution of checklists and diagrams outlining the process to eliminate common triggers. Woodhull also addresses patients’ home environments, distributing environmental control products such as allergen-proof pillow and mattress covers free of charge. Woodhull has renovated the emergency department with a state-of-the-art asthma treatment room, which offers patients assistance with their paperwork while they begin treatment. This fast-track approach has resulted in easier and more effective access to asthma treatment in emergency situations. The results of Woodhull’s work are captured in its Asthma Registry: The number of visits to the pediatric asthma clinic more than doubled between 2008 and 2009, which correlated to a 58 percent reduction in asthma related emergency department visits and 67 percent decrease in hospitalizations.

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2009 Winners

Bethlehem Partnership for a Healthy Community – The Asthma Initiative

The Bethlehem Partnership for a Healthy Community logo
Bethlehem Partnership for a Healthy Community - The Asthma Intiative

Gina McCarthy, then Assistant Administrator, Office of Air and Radiation, U.S. EPA, and Lisa Jackson, Former Administrator, U.S. EPA, present Award to (left to right) Mary Mittl, Susan Madeja and Elizabeth Roth of the Bethlehem Partnership for a Healthy Community — The Asthma Initiative

Based on the premise that strong patient-provider interaction is key to asthma management, the Bethlehem Partnership for a Healthy Community identifies and educates high-risk children and their families through the school system, improves access to preventive services and care, and provides up-to-date asthma education to the medical community. In partnership with St. Luke’s Hospital and the Bethlehem Area School District, the initiative helps to manage asthma through multiple access points: school-based health clinics, Open Airways Programs, mobile school health clinics, and St. Luke’s Hospital Clinic. The program educates and supports clinical care teams by providing annual education and training to health care providers and coalition partners. Patient education includes multiple, bilingual home visits and thorough patient follow-up. Working with the Bethlehem Health Bureau, the initiative evaluates homes for environmental triggers while distributing trigger-reducing items (such as mattress covers and green cleaning supplies), provides one-on-one education to families, and assists tenants in contacting landlords in order to correct mold and cockroach issues. Through a successful partnership with Lehigh University, the program expanded to address outdoor air quality during the home visit survey. The initiative has proven to be effective: From 2007-2008, multiple asthma-related pediatric emergency department visits for individual patients decreased by 56 percent.

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Boston Medical Center/Boston Public Health Commission

Boston Medical Center/Boston Public Health Commission logo
Boston Medical Center/Boston Public Health Commission

Gina McCarthy, then Assistant Administrator, Office of Air and Radiation, U.S. EPA, and Lisa Jackson, Former Administrator, U.S. EPA, present Award to (from left to right) Margaret Reid and Dr. Megan Sandel of the Boston Medical Center Boston Public Health Commission

Staffed by pulmonologists, allergists, public health staff, and an extensive translation services program—with over 30 languages spoken—Boston Medical Center’s (BMC) collaboration with the Boston Public Health Commission (BPHC) provides excellent clinical and environmental care and promotes improved asthma self-management for the city’s underserved populations. The program educates patients about asthma management and environmental triggers, facilitates access to needed services (medical legal partnership, housing, and insurance), and promotes strong provider-patient relationships that contribute to improved patient outcomes. BMC’s environmental focus includes partnerships with several Boston agencies to launch the Breathe Easy at Home Program, a Web-facilitated program that gives health professionals a way to report potential housing code violations that may worsen patient asthma, and the Boston Inspectional Services Department responds to reports by working with property owners to remediate the situation. In striving to offer effective and accessible primary care and outpatient services, BMC successfully works with their most utilized health plans to provide asthma education and case management services and provides exceptional care without exception. The city of Boston is reaping the benefits of this powerful collaboration. The hospitalization rate for Boston’s children with asthma has decreased 39 percent and emergency department visits are 16 percent lower.

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California Department of Public Health/Center for Chronic Disease Prevention and Health Promotion

California Department of Public Health logo
California Department of Public Health/Center for Chronic Disease Prevention and Health Promotion

Gina McCarthy, then Assistant Administrator, Office of Air and Radiation, U.S. EPA, and Lisa Jackson, Former Administrator, U.S. EPA, present Award to (from left to right) Dr. David Nunez, Sara Campbell-Hicks and Dr. Rick Kreutzer of the California Department of Public Health � Center for Chronic Disease Prevention and Health Promotion

Serving nearly 38 million people, the California Department of Public Health - Center for Chronic Disease Prevention and Health Promotion provides multi-faceted asthma management and care to children and adults through programs based in schools, workplaces, and the community at large. The Work-Related Asthma Prevention Program provides customized educational materials to underserved adults with workplace-related asthma, analyzes data to identify high-risk industries and appropriate interventions, and conducts site investigations. The California Breathing Program conducts school-based programs that emphasize environmental interventions, train staff and childcare providers, and offer incentive-based awards to schools that create healthy environments. Community-based grants to local organizations fund a range of interventions including technical assistance on topics such as pest management in housing developments, second-hand smoke reduction, and mold intrusion training for code enforcers. Environmental interventions are complemented by the California Asthma Public Health Initiative where clinicians assess individual allergen sensitivities, educate families, and often provide free products to reduce exposure to triggers. In participating clinics, the number of children with written asthma action plans increased 84 percent, and asthma-related emergency department visits dropped by 78 percent.

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Genesee County Asthma Network

Genesee County Asthma Network logo
Genesee County Asthma Network

Gina McCarthy, then Assistant Administrator, Office of Air and Radiation, U.S. EPA, and Lisa Jackson, Former Administrator, U.S. EPA, present Award to (from left to right) Pauline Sidiropoulos MSW, Michelle Cox RRT, Jan Roberts RN, Joni Zyber RN, and Lori McQuillan CHES of the Genesee County Asthma Network

Focused on inner-city children in the Flint, Michigan area, the Genesee County Asthma Network (GCAN) is a comprehensive community-based program that delivers high quality asthma care through asthma and allergy specialists, physicians, and two registered nurses who are certified asthma educators. The asthma educators complete up to 200 home assessments each year where they identify asthma triggers, while an accompanying social worker identifies potential barriers to successful asthma management such as financial hardship, transportation, or family issues. Incentives and awards motivate patients and families to follow through with self-management advice. Classroom assessments (that identify and encourage schools to fix environmental problems) often complement home inspections and ensure that patients are well prepared to address their environmental asthma triggers. Asthma educators accompany patients on clinical visits to review medications and help develop a personalized asthma action plan. With the support of Hurley Medical Center and working with numerous partners in the community— including the American Lung Association, faith-based organizations, health providers and payers, and Habitat for Humanity, which built an asthma-friendly home for one patient’s family—GCAN has produced dramatic results. Asthma-related emergency department visits have dropped by 45 percent; hospitalizations by 25 percent.

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Seton Asthma Center

Seton Asthma Center logo
picture of the award ceremony for the Seton Asthma Center

Gina McCarthy, then Assistant Administrator, Office of Air and Radiation, U.S. EPA, and Lisa Jackson, Former Administrator, U.S. EPA, present Award to (from left to right) June Niblett, Steve Conti and Kenna Griffith of the Seton Asthma Center

The Seton Family of Hospitals formed the Seton Asthma Center in 2004 to respond to a rise in asthma-related pediatric emergency department visits and hospitalizations, especially among economically disadvantaged and underserved populations. The Center’s case management workers, all registered respiratory therapists, promote improved patient self-management in bilingual patient education sessions that include in-home environmental assessments, training on appropriate use of medications and peak flow meters, and the development of personalized asthma action plans. The asthma action plan serves as a communication tool between the primary care provider, the school nurse, and the patient. The case managers review each asthma action plan quarterly to ensure each patient has a current, effective plan in place. The Center also operates a mobile caravan that makes monthly visits to public schools to deliver asthma care to uninsured and indigent students. Case managers have partnered with the Central Texas Asthma Coalition and the American Lung Association’s Lung Health Initiatives Committee to raise public awareness, educate providers, and collect surveillance data. This partnership has led to the use of a standardized set of metrics to assess the burden of asthma in the community. For patients enrolled in the program, asthma-related emergency department visits have dropped by 75 percent, and the number of in-patient visits has decreased by 85 percent.

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2008 Winners

The Asthma Network of West Michigan (ANWM)

the asthma network logo
picture of award ceremony for The Asthma Network of West Michigan (ANWM)

Elizabeth Cotsworth, Former Director, Office of Radiation and Indoor Air, U.S. EPA, and Beth Craig, Former Deputy Assistant Administrator, Office of Air and Radiation, EPA, and Chris Draft, Retired NFL player, present Award to (from left to right) Karen Meyerson, Mark Huizenga and Lil De Laat of the Asthma Network of West Michigan (ANWM)

The Asthma Network of West Michigan (ANWM) is a community coalition that provides comprehensive home-based case management to 94,500 children and adults with asthma in West Michigan. ANWM has demonstrated impressive results including improved health outcomes and cost savings. This success has led to a partnership with Priority Health (a winner of the 2007 National Environmental Leadership Award in Asthma Management) who agreed to reimburse ANWM for its home visit program. This partnership with Priority Health is the nation’s first agreement between a grassroots coalition and a managed care plan. ANWM now has contracts with five local health plans and its asthma management program provides asthma education, coordination with health care providers, development of asthma action plans, home environmental assessments, and social service support. ANWM’s comprehensive care costs $2,500 per person annually and has led to a 64 percent decrease in hospitalizations and a 60 percent decrease in ER visits. These improved health outcomes resulted in approximately $800 in net health care cost savings per child per year.

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The Monroe Plan for Medical Care

picture of award ceremony for The Monroe Plan for Medical Care

Elizabeth Cotsworth, Former Director, Office of Radiation and Indoor Air, U.S. EPA, and Beth Craig, Former Deputy Assistant Administrator, Office of Air and Radiation, EPA, and Chris Draft, Retired NFL player, present Award to (from left to right) Dr. Joe Stankaitis and Deborah Peartree of the Monroe Plan for Medical Care

the monroe plan logo
The Monroe Plan for Medical Care is a managed care organization, located in the Rochester, New York area. The Monroe Plan covers 5,633 children with asthma in Monroe County and 12 neighboring rural counties. With a high asthma burden among children in the area, the Monroe Plan saw trends in pediatric asthma and noticed high admission rates that disproportionately affected minorities. In partnership with ViaHealth, a health care delivery system, the Monroe Plan launched a program to shift asthma care away from emergency services and inpatient care and toward improved patient self-management. The program now covers all of the plan’s members with moderate to severe pediatric asthma and includes assistance to providers in creating asthma action plans and comprehensive provider and member education. Home assessments are conducted by bilingual asthma outreach workers to identify and reduce environmental triggers. As a result of these interventions, ER visits decreased from 1.1 visits per person to .95 visits per person over the first three years of the program. Inpatient admissions decreased from 98.3 admissions per thousand to 84.15 per thousand in the first three years of the program.

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The University of Michigan Health System Asthma Quality Improvement Steering Committee

picture of award ceremony for The University of Michigan Health System Asthma Quality Improvement Steering Committee

Elizabeth Cotsworth, Former Director, Office of Radiation and Indoor Air, U.S. EPA, and Beth Craig, Former Deputy Assistant Administrator, Office of Air and Radiation, EPA, and Chris Draft, Retired NFL player, present Award to (from left to right) Karla Grossman, Dr. Annie Sy, Dr. Steven Bernstein, DeAnn Vansickle, and Dr. Georgiana Sanders, of the University of Michigan health System (UMHS)

university of michigan logo
The University of Michigan Health System (UMHS) is a non-profit health care provider serving 12,214 adults and children with asthma in four counties in Southeastern Michigan. Since 1997, the UMHS Quality Improvement Steering Committee, a group of multidisciplinary volunteers, has guided improvements in asthma care across the health system. The UMHS Asthma Management Program includes specific, population-based programs for high-risk asthma populations and in-home asthma education through the Michigan Visiting Nurses Asthma Home Environmental Assessment Program. Web-based, standardized NHLBI-compatible guidelines are available to all providers, including standardized Asthma Action Plans and education templates. A comprehensive, validated, all-payer database of asthma patients helps UMHS identify areas of need for targeting interventions and assessing outcomes. As a result of these programs, UMHS achieved a 50 percent decrease in asthma-related hospitalizations from July 2005 to June 2007. Between June 2006 and June 2007, participants in the home assessment program had a 60 percent decline in ED visits and an 85 percent decrease in hospitalizations.

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2007 Winners

Priority Health, Grand Rapids, Michigan

Priority Health logo
Priority Health is a non-profit health plan that serves more than 19,000 people asthma in 43 Michigan counties. In the late 1990s, Priority Health recognized the need for home-based asthma care that includes environmental trigger management. To deliver effective home-based care, Priority Health formed a first-of-its-kind partnership with the Asthma Network of West Michigan (ANWM). Priority Health uses ANWM’s case managers and social workers to increase its ability to effectively assess and educate its members. ANWM provides home-based education; home environmental assessments; and resources to reduce exposures to environmental asthma triggers.

picture of award ceremony for Priority Health, Grand Rapids, Michigan

From Left: Ruth Kavanagh; Elizabeth Cotsworth, Former Director, Office of Radiation and Indoor Air, U.S. EPA; Mary Cooley

Today, all of the plan’s members with moderate or high risk asthma within ANWM’s service area receive intensive case management that integrates patient education, home-based environmental interventions, and evidence-based clinical care. Priority Health also reimburses ANWM for meeting with providers to develop individualized care plans. These plans are the cornerstone for determining appropriate interventions, monitoring, and follow-up. Priority Health provides incentives to their providers to ensure that members use asthma medications appropriately and to implement the Planned Care Model for asthma. The results of these programs include improved medication use and significant reduction in the number of emergency room visits and hospitalizations for asthma. Utilization data show that emergency room visits were reduced from 72 visits per thousand patients in 2002 to 40 in 2006 for commercial members, and from 250 to 189 for Medicaid members. Savings over time for members are estimated at $1.7 million, and the long-term return on investment (ROI) for Priority Health is 2.1:1.

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MaineHealth AH! Program, Portland, Maine

MaineHealth AH! logo
MaineHealth's service area covers 90,675 patients with asthma, including 27,156 children in southern, central, and western Maine. The AH! (Asthma Health) Program combines standards-based clinical care in the patients’ communities with robust indoor and outdoor environmental asthma management. Patients receive in-depth counseling to manage exposures to environmental triggers in home, school, and work settings. Educational materials are culturally appropriate, translated into six languages, and use pictograms for low literacy populations. The Program supports wide dissemination of information on outdoor asthma triggers including ozone and particulate matter. The AH! Program has a strong presence outside its clinical settings, having built long-term relationships with community organizations, schools and daycare centers, public health departments, and others. The AH! Program also takes leadership positions to advocate for municipal, state, or national public policy actions -- such as bans on tobacco use in public places -- that create asthma-friendly environments.

picture of award ceremony for MaineHealth AH! Program, Portland, Maine

From Left: Donna Levi; Julie Osgood; Elizabeth Cotsworth, Former Director, Office of Radiation and Indoor Air, U.S. EPA; Rhonda Vosmus

The AH! Program is strongly committed to providing integrated health care; they have created advisory committees that provide regular communication and coordination with primary and specialty care physicians, asthma educators, care managers, home health nurses, and others in the community interested in asthma care outcomes. The results of these impressive efforts have reduced emergency room use, hospitalizations, and missed school and work days, and improved physician adherence with national guidelines for asthma care. Evaluations at six months post-intervention show a 61 percent reduction in appropriate emergency room use and a 29 percent reduction in hospitalizations. Research over the past nine years shows that the improvements at six months are largely sustained. Maine Medical Center, one of MaineHealth’s member hospitals, achieved a reduction in emergency room visits from 81 percent to 20 percent and hospitalizations from 32 percent to 3 percent. These improved outcomes resulted in 2006 avoided costs of $61,635 on emergency room visits and $411,470 on hospitalizations.

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2006 Winners

Blue Cross of California, State Sponsored Business Unit

blue cross of CA logo
Blue Cross of California, State Sponsored Business Unit (SSB), has designed a Comprehensive Asthma Intervention Program (CAIP) to improve care for California Medi-Cal and Healthy Families members with asthma. Because standard asthma management programs seldom address the needs of all members in a culturally and linguistically diverse, low-income population, like the Blue Cross SSB membership, who often face environmental health challenges, CAIP encompasses innovative partnerships with members, providers, academic institutions, public health organizations, and communities, to maximize opportunities for improved asthma outcomes.

picture of award ceremony for Blue Cross of California, State Sponsored Business Unit

Elizabeth Cotsworth, Former Director, Office of Radiation and Indoor Air, U.S. EPA, presents Award to the Blue Cross of California, State Sponsored Business Unit

CAIP includes individual member outreach; resources and incentives for physicians and pharmacists to encourage improved asthma care; Plan/Practice Improvement Project (PPIP), a collaboration modeled after the Institute for Healthcare Improvement’s Breakthrough Series, to enhance asthma chronic care through practice-specific redesign; Valley Air Quality Project, a county-specific partnership to improve community responses to environmental air pollution affecting the respiratory health of Fresno County, where asthma prevalence is high.

"I’m extremely honored by our award from the EPA and proud of our growing partnership with them. The EPA is one of the premier organizations in our country that is fighting for higher standards for clean air, a cause that SSB celebrates. SSB looks forward to an ongoing relationship that is rooted in our common goal to create a healthier world for our members and their communities."

John Monahan, President of Blue Cross of California State Sponsored Business (SSB).

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Impact DC logo
picture of award ceremony for IMPACT DC

(from left to right) Abisola Ayodeji, Beth Dunbar, Jordan Schmidt, Dr. Radha Chirumamilla, Alicia Newcomer, Deborah Quint, Dr. Stephen Teach, and Terry Ahern of IMPACT DC

Improving Pediatric Asthma Care in the District of Columbia (IMPACT DC) Asthma Clinic targets inner-city, minority and disadvantaged children who suffer disproportionate asthma morbidity and mortality. Most live with challenging social and environmental circumstances with daily exposure to multiple asthma triggers. Their families often have a tenuous connection with their primary care providers, and thus frequently rely on emergency departments (EDs) for asthma care. While EDs typically provide excellent episodic care for acute asthma exacerbations, they usually pay little attention to longitudinal management issues. As a result, many families view asthma as an episodic problem instead of a chronic disease requiring daily management. IMPACT DC’s fully validated program recruits from a large urban ED (Children’s National Medical Center) and focuses on three distinct domains: environmental control, medical management, and longitudinal care. In a prospective clinical trial, it improved multiple patient outcomes. It is an innovative, replicable, and cost-efficient national model for asthma mitigation among children in the inner city.

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2005 Winners

Optima Health

optima health
picture of award ceremony for Optima Health

Elizabeth Cotsworth, Former Director, Office of Radiation and Indoor Air, U.S. EPA, presents Award to Optima Health

The staff at Optima Health Plan – the managed care division of Sentara Health Care that operates in southeastern Virginia – noticed a disturbing trend: despite pharmacological advances in asthma therapy, the number of emergency room visits, hospitalization rates, and medical costs for asthma patients continued to rise. The quality of life for the approximately 8,500 asthma patients enrolled in Optima’s plan was not as high as Optima’s staff thought it should be and staff was committed to helping their asthma patients understand everything they could do to prevent asthma attacks. Optima’s staff also knew that education and management advice were often most effective when delivered at home so they developed an innovative “Asthma Life Coach” program that sends nurses and respiratory therapists to asthma patients’ homes where they work with patients and their caregivers to identify environmental triggers, such as secondhand smoke, cockroaches, dust mites, mold, and other sources that can trigger asthma attacks. Optima’s staff understood that many asthma patients simply don’t know that things in their homes, schools, and other environments can trigger asthma attacks and that many asthma triggers can be eliminated through simple management techniques. The Asthma Life Coach program provided an easy way for Optima’s asthma patients to learn about environmental asthma triggers and how to reduce exposure to them. Optima’s staff visited patients at home where they surveyed their environments, reviewed their use of medicines, and developed individualized written asthma treatment plans incorporating medical and environmental components. Optima’s Asthma Life Coaches serve as coordinators helping patients take action based on disease management suggestions and physician recommendations and ensuring that patients know how to use medical and environmental controls to manage their asthma. Since instituting the Asthma Life Coach program in 1999, Optima has seen a significant decrease in the number of hospitalizations and emergency room visits for their members with asthma.

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Children's Mercy Hospitals and Clinics

Children's Mercy Hospitals
picture of award ceremony for Children's Mercy Hospitals

Jeff Holmstead, Former Assistant Administrator, Office of Air and Radiation, EPA, presents Award to the Children's Mercy Hospitals and Clinics

Children’s Mercy Hospitals and Clinics — serving families in Nebraska, Oklahoma, Kansas, and Missouri — uses a creative approach for managing pediatric asthma. Children’s Mercy trained a team of asthma educators to implement a three-part environmental asthma management program that included education for providers and staff; personalized case management and education for families with high hospital utilization due to asthma; and in-home, school, and day care environmental assessments to determine the presence of asthma triggers. Children’s Mercy determined that for those patients with severe cases of asthma, home-based, hands-on education about the common environmental asthma triggers was critical to ensuring that patients gained control over their asthma and made the connection between their asthma symptoms and environmental triggers in their home environment. During the home assessments, Children’s Mercy staff conducts a comprehensive environmental and safety assessment that identifies common environmental asthma triggers. Based on the home assessments, asthma educators provide personalized environmental health action plans to help patients and their families identify their asthma triggers and to reduce these triggers in their home. Through a creative partnership with the Healthy Homes Network for Kansas City, and funded by a HUD Healthy Homes Demonstration grant, qualifying families are provided up to $2,000 worth of home supplies and repairs to try to reduce environmental asthma triggers. As a result of Children’s Mercy’s efforts, patients and their families know more about what triggers their asthma and how to control asthma symptoms. Children’s Mercy has seen fewer emergency department visits and hospitalizations since the program’s inception.

"We were very honored to win this award on behalf of Children’s Mercy Hospital and Family Health Partners. Receiving this award empowered us to continue the great work we were doing and take it to the next level. Our health plan received an additional state contract because of our success and award winning management of asthma and indoor environments.

Our goal is to take what we learned from our hard work on effective asthma management with families and apply this knowledge to building effective asthma management for the entire community. The more we can improve awareness education in our community, the healthier our community will be for all children."

Kevin Kennedy, Program Manager, Environmental Health Program,
Children’s Mercy Hospitals and Clinics

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2005 Honorable Mentions

Neighborhood Health Plan of Rhode Island

Founded in 1993, Neighborhood Health Plan of Rhode Island (NHPRI) is the leading provider of health insurance to low income and minority children and families in the state, serving nearly 75,000 Medicaid members.  NHPRI’s asthma program has one simple goal: to enable members with persistent asthma to live normal, healthy lives. To achieve their goal, NHPRI developed a multi-faceted education and outreach program to address environmental management of asthma, with educational modules tailored to the needs of providers, asthma patients and their families. NHPRI gave providers clinical practice guidelines; continuing medical education credits for learning about environmental asthma management; and incentives for referring patients to the home visit component of NHPRI’s asthma management program. NHPRI also offers a range of services for patients. The services vary depending on the patient’s asthma severity. Patients diagnosed with severe persistent asthma and who have been hospitalized or visited an emergency room automatically receive an initial call or home visit from an Asthma Case Manager and ongoing interactions to educate the patient and family about comprehensive asthma management. NHPRI developed a more specialized home visit program called “Beating Asthma,” for patients with persistent asthma living within three high-need communities. To reach those patients, NHPRI trained bilingual and bicultural Asthma Advocates to conduct home visits that combine education about medical management with an assessment of environmental asthma triggers found in the home and information on controlling them. Patients and families that participate in the “Beating Asthma” program, receive a calling card, peak flow meter, a written, personalized Asthma Action Plan, allergy-free mattress and pillow covers, and a supermarket gift card. NHPRI’s preliminary results indicate that participants in the “Beating Asthma” program have experienced a reduction in emergency department visits, use of rescue medications, and unscheduled outpatient visits. NHPRI’s approach targets healthcare providers and asthma patients to ensure that each group receives the information it most needs to reduce the burden of asthma for Rhode Island families.

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Connecticut Children’s Medical Center Easy Breathing Community Initiative

The Easy Breathing Program improved asthma care by educating primary care clinicians about disease management standards and the importance of environmental asthma management. The program was launched in 1998 to serve a poor, urban community in Connecticut where approximately 85% of the children served were Medicaid and SCHIP-eligible. The Easy Breathing Program has been so successful and well-documented that, over time, it has been replicated by healthcare providers and clinics throughout Connecticut and across the country. Easy Breathing focuses on training healthcare providers in the appropriate use of pharmacologic therapies, environmental management, and culturally appropriate patient outreach. Providers receive asthma management education in phases – starting with guidance on recognizing asthma, followed by tips on successfully managing it. As providers moved through the phases of learning, they requested additional information and outreach materials that they could use with their patients. Easy Breathing provided culturally appropriate materials for providers to use to educate patients from all backgrounds and language communities. Easy Breathing coached providers on identifying a patient’s asthma severity, skin testing patients to identify allergens that trigger each patient’s asthma, and developing personalized asthma treatment plans with patients and their caretakers that include guides on using appropriate medications and following environmental asthma management techniques. In collaboration with the Hartford Pediatric Asthma Coalition, Easy Breathing developed a standardized home environmental assessment tool to survey home environments and make recommendations to families living with asthma on how to reduce environmental asthma triggers. To date, over 55,000 children in Connecticut have been enrolled in Easy Breathing and participants have shown a significant decline in hospitalizations, emergency department visits, and an increase in the appropriate use of medications.

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