Asthma Program

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Conduct a preventative-based asthma clinic with planned visits.
All too often, asthma care is geared to respond to patients who are either at the threshold of an asthma episode or actually having an episode. Care follows a scenario of treating patients to get over the crisis and back to normal, and then releasing them. This approach assumes asthma to be an acute illness. In contrast, YES WE CAN clinical care is organized to address the chronic nature of asthma. The emphasis is on preventing asthma episodes and controlling asthma day-to-day. This reordering of traditional clinical care for asthma includes:

1. implementing an asthma cluster clinic care model
2. sequencing a care pathway of planned clinic visits, home visits, and follow-up clinical assessment phone calls
3. frequently reassessing asthma symptom control
4. assuring a written Asthma Action Plan for all children
5. having an "Asthma Depot" for all supplies and devices
6. making tools available such as a database, posters, materials with embedded National Asthma Education and Prevention Program (NAEPP) guidelines to cue providers during clinical encounters.

The asthma clinic is a time-efficient, patient-focused, prevention-based operation. It is relatively simple to implement, and is aligned with the NAEPP asthma guidelines. The template is a "cluster" clinic model consisting of coordinated, back-to-back planned appointments during a specified block of time with the asthma staff and equipment on hand. Scheduled patients may be there for the first time, or for return visits. The cluster clinic provides an opportunity to do an in-depth assessment or follow up, to diagnose asthma and establish the patient’s severity, to identify the patient’s allergies and other triggers, and to formulate or re-evaluate the best clinical management. The child and the family receive education from all three members of the asthma team, each time presented in slightly different form and tailored to the family’s educational needs. Table 1 [opens in new window] outlines the key features of the YES WE CAN Asthma Clinic Model.

A child with unstable asthma and, frequently, complicating social factors enters the YES WE CAN program generally as a referral from an ED, hospital, or the primary care physician. Over the next several months the child and caregiver will likely make three planned visits to the asthma clinic and have anywhere from one-to-three planned home visits by a CHW. A series of clinical assessment phone calls from the clinical case manager to the child’s caregiver are interspersed with these clinic and in-home interventions. During these calls, the child’s level of asthma control is discussed, and the caregiver is provided help to improve control as needed. This sequenced care pathway is shown graphically in Figure 1. [opens in new window]

The job of the asthma team would be made easier if all enrolled children needed the same level of care. However, uniformity in pediatric asthma care is not practical or realistic. Population management requires stratifying or sorting the children with asthma into distinct subpopulations according to their risk level. Each of these subpopulations has different care needs and requires a different intensity of care. Children and families at low risk need fewer, less intensive services to achieve good asthma control and master asthma self-management skills. Children at higher risk require more intensive services. Population management enables the asthma team to direct the use of resources in a way that will result in the greatest improvement in asthma control for the population as a whole.

Medical criteria alone (hospital admissions, ED visits, and beta agonist use) are not sufficient to identify families in need of higher levels of care to stabilize their child’s asthma. Social and psychological issues also coincide with significantly higher risk of poorly controlled asthma. Low-income families are confronted with some social barriers and psychological challenges that make managing their child’s asthma more difficult. Table 2 [opens in new window] lists examples of social/psychological risk criteria that are used to establish a stratification model based on risk.

The YES WE CAN risk stratification model can be illustrated graphically as a pyramid sliced into four sections depicting how a pediatric asthma population can be sorted into four risk levels, with each related to a level of service. The base of the pyramid, Level 1, represents the largest percentage of children: children with asthma that is generally under control. Level 2 indicates children who need basic case management. Children in Level 3 require moderate case management, and children in level 4 require intensive case management. This sorting of cases is used for planning care and for thinking through types and levels of interventions. YES WE CAN clinics use the risk stratification model shown in Figure 2 [opens in new window] as a guide in caring for enrolled children with asthma.

The goal is to target those children and families that are most in need of services such as home visits and close clinical care management. Families that fall into levels 2 and 3 of the risk stratification pyramid benefit most from these resource-intense interventions.

Table 3 [opens in new window] presents the four levels of care and the most appropriate provider of care for each level, defines the population in each level, and summarizes the goals and interventions for each level.

Clinical case management involves coordinating care and interventions to optimize quality patient care, improve continuity of care, and ensure there are no gaps in services and no duplication of services. The clinical case manager coordinates the three components of clinical case management.

a. Case finding and case management
The clinical case manager coordinates the review, screening, and processing of referrals to the program, and tracks families through the care path. The clinical case manager calls the family when they do not follow up on a referral to the clinic, ensures the child is enrolled in the program, and is responsible for case-management of high-risk children in the program. The clinical case manager coordinates the asthma team and the clinic activities including preparation, logistics, patient flow, consultations, referrals, and follow-up appointments, and performs individual patient procedures, treatments, and tests. In addition, the clinical case manager works with the clinician to monitor asthma control and adjust medications.

b. Asthma self-management education
The clinical case manager provides family education on asthma and asthma self-management including trigger identification and trigger avoidance measures, appropriate use and understanding of medications (actions, side effects, dosage and sequencing), and self-monitoring. Assessing technique and refining skills in the use of the peak flow meter, the metered dose inhaler (MDI), and spacer are other responsibilities.

The educational protocols are based primarily on Pediatric Asthma: Promoting Best Practice-Guide for Managing Asthma in Children, 2002. The Guide was developed by the American Academy of Allergy, Asthma and Immunology in collaboration with the American Academy of Pediatrics, the National Heart, Lung, and Blood Institute and the NAEPP. The guide is based on and is consistent with the Expert Panel Report 2 (EPR-2): Guidelines for the Diagnosis and Management of Asthma, published by NAEPP in 1997.

c. Team coordination
The clinical case manager maintains communication with departments, hospitals, and community organizations and agencies to ensure referral systems are working to promote continuity of care and to ensure procedures and systems function smoothly. The clinical case manager also consults with the patient’s primary care providers to provide regular updates on the status of their patients.

Community healthcare workers (CHWs) are professionally educated, trained, and certified men and women who come from the communities of the families being served and are fluent in the family’s primary language. CHWs aid families in assessing their needs and strengths by helping them to identify problems and barriers to optimum asthma self-care. CHWs provide educational information to the families and assist them with environmental remediation during home visits. CHWs also conduct social assessments with primary caregivers to discover any problems that might keep the family from concentrating on their child’s asthma. Families in San Francisco living in old housing often experience excessive mold and mildew. CHWs have advocated on behalf of families with their landlords (often the public housing authority) to make roof repairs, replace windows, and clean, caulk, and paint mold-affected areas. In some circumstances, CHWs have assisted families in acquiring more suitable housing. CHWs help families acquire insurance coverage, and they resolve transportation and school issues that affect asthma management. CHWs refer caregivers to social services or to a social worker when the family’s specific social needs extend beyond the CHW’s capacity. CHWs inform the clinic how well the child is complying with the medication regimen and provide an additional resource in the clinic for family orientation, asthma education, and scheduling.

The clinician is first and foremost a champion for the program, a strong advocate within the community and is the leader of the asthma team. As program champion, the clinician makes presentations in the community to improve understanding and to gain support for the program. Strong advocacy translates not only to program buy-in, but it can also result in obtaining volunteer help, donations of equipment, furnishings, and asthma prevention materials needed to launch and sustain the program.

Start-up activities are the responsibility of the clinician. A dry run of the clinic process ensures that each member of the asthma team understands the individual protocols and can perform their assigned tasks efficiently and effectively. The dry run includes a review of the use of the equipment, the medical forms, the registry, use of available facilities, and the asthma-education lessons. It also includes handling patient concerns, especially on the first visit. Special attention is given to incorporating the CHW into the clinical team.

The program is carried out in community primary care settings where the majority of the children receive their asthma care. The YES WE CAN clinic combines the strengths of medicine and public health. A multidisciplinary asthma team guides each child through a care pathway that includes clinic visits, home visits, and clinical assessment follow-up phone calls. The team conducts clinical assessments and provides asthma education based on the NAEPP Guidelines. The CHW carries out an assessment of the home environment and provides guidance for reducing exposure to asthma triggers. An essential component of the model is the social support and the linking of families to community resources. The team takes into account the context of families’ lives so that strategies for improving the child’s asthma are practical and reality-based. The YES WE CAN approach focuses on factors that make an individual child’s asthma hard to manage, and then on ways to improve asthma control. The asthma team, working with the family, develops a care plan. The care plan outlines specific objectives, goals, and interventions designed to address the family’s needs as identified during the asthma clinic and home visits. The care plan proposes steps that the asthma team, other providers, and the family will take to improve the family’s ability to manage their lives and the child’s asthma. The care plan is an active document that changes over time as the family’s needs are addressed and change.

The Program was operated bilingually in English and Spanish, with some educational materials also provided in Cantonese.

The asthma registry is an important management tool that aids the asthma team in carrying out the clinic and managing patient caseload. Basically, the registry incorporates all of the ongoing information about patients in the asthma program. This stand-alone data base is essential for identifying, stratifying, and tracking asthma patients. During clinic visits, the asthma team members input patient health data into the registry (for example, symptoms, morbidity, spirometry, blood pressure, weight and height), asthma diagnosis and severity, and other information such as prescriptions and follow-up appointments. The registry is used to track patients to prevent loss to follow-up from families simply dropping out of the program, and to track interventions for each case. Asthma team members have on-demand access to the registry and input data on laptop computers during the clinic visit.

Most children are enrolled into the program following a visit for their asthma to urgent care, the ED, the hospital or their primary care provider. If families do not follow through on the referral, the clinical case manager contacts the family and invites the child and parent/caregiver to enroll in the program. If the family agrees, the child is scheduled for an asthma clinic visit.

Orientation
In a typical first clinic visit, the CHW meets the caregiver and the child when they arrive at the clinic. The CHW conducts a short orientation that introduces the family to the clinic, the facility, and the program; explains what they can expect during the visit; and tells them the expected length of the visit. The CHW introduces the caregiver to the "team" concept for addressing the child’s asthma, and explains the family’s role as part of the team.

Intake Questionnaire
The clinical case manager or designated medical assistant uses the intake questionnaire to question the caregiver (and the child when appropriate) about the child’s asthma in order to complete an asthma history. The questionnaire addresses morbidity, history of asthma and related illnesses, usual asthma symptoms, asthma triggers, home environment, and asthma control. Questions from the family about the child’s asthma are also recorded. The caregiver is asked if there are any social barriers or issues that stand in the way of managing the child’s asthma, and responses are recorded.

Asthma self-management education
The family views a KP/NC video titled "Your Child and Asthma," in English, Spanish or Cantonese. The clinical case manager or the CHW presents asthma self-management instruction and answers questions. The instructional format is one-on-one based on the individual family needs as determined by parent and child asthma knowledge deficits and their individual concerns. The initial educational component is centered on helping the child and caregiver to understand the medications and how they should be administered, to recognize an asthma attack and know what to do if one occurs, and to identify personal triggers and learn how to avoid them. Details about the educational program are described in Section V, Patient and Family Education.

Skin testing and spirometry
For children aged 5 years and older, the clinical case manager administers an allergy skin test for mites, cockroaches, cats, dogs, indoor mold, and local grasses and trees. The clinical case manager conducts peak flow test while observing the child’s technique, and assists the child in improving performance. Spirometry testing is also done. Following two-to-four puffs of albuterol and a 20-minute wait, post-bronchodilator spirometry is performed, and the skin test results are read.

Assessment, diagnosis, and treatment
The clinician becomes acquainted with the child and caregiver and reviews the child’s asthma health history from the intake questionnaire. The clinician conducts a physical assessment of the child, makes an asthma diagnosis, or confirms the previous asthma diagnosis, and determines asthma severity. The clinician then interprets the spirometry results, prescribes a treatment plan based on the NAEPP guidelines, provides prescriptions, and develops a written Asthma Action Plan for the child. Then the clinician teaches the family how to use the plan.

A medicine box is provided to the family at the first clinic visit. It is a rectangular plastic container with a lid, and is about the size of a shoebox. In addition to storing the asthma medications there, children keep their peak flow meters and spacers in the medicine box.

Follow up
Prior to terminating the visit, the CHW schedules the home visit and also schedules the next asthma clinic visit. The CHW answers any questions about asthma education or the program, and discusses the next steps for any urgent social need identified by the family during the visit. The clinical case manager informs the caregiver about the clinical assessment telephone call that will follow the home visit.

Flow Chart 1 [opens in new window] shows how a typical patient would go through an initial asthma clinic visit.

Within a few days following the first asthma clinic visit, the CHW telephones the family to confirm the home visit date and time. In preparation for the visit, the CHW reviews the results of the first clinic visit, including the results of allergy tests or other tests and notes the medications prescribed and the known asthma triggers for the child. The CHW assembles items needed for the visit, which may include copies of the test results, mattress and pillow covers, videos or other educational materials, copies of the child’s Asthma Action Plan, and important phone numbers for the family.

At the home, the CHW goes over a prospective plan for the visit and obtains concurrence from the caregiver before proceeding. The CHW’s objectives are to:

• describe the role of the CHW as an ally to the family who will help them manage the child’s asthma and as an advocate in the community who will help resolve barriers the family faces to good asthma care
• answer questions
• verify that the prescriptions have been filled and the medications are being taken as prescribed
• observe how the child takes the medicine
• show the caregiver how to organize the medicine box and where to place the Asthma Action Plan
• review the results of allergy testing with the caregiver
• ask questions about triggers of the child’s asthma and when episodes are most likely to occur
• verify asthma knowledge and review asthma self-management educational materials as needed
• walk through the house (especially the child’s bedroom) with the caregiver with a trigger checklist, and note any visible asthma triggers
• if the child is allergic to dust mites, help the caregiver place mattress and pillow covers on the child’s bed
• determine the caregiver’s strengths and level of self-confidence in dealing with the child’s asthma
• assess barriers to appropriate care and disease management such as not having a primary care provider, no health insurance, housing issues, employment issues, childcare problems, transportation difficulties, family issues, language barrier
• ask the caregiver what they want to work on and work with them to develop a plan that includes actions the family can take to reduce triggers in the home

The clinical case manager initiates the clinical assessment telephone call to the child’s caregiver. Clinical assessment calls provide for close monitoring of the clinical progress of each child. This helps to optimize the family’s ability to manage their child’s asthma effectively and to get the child on the right medication at the lowest effective dose before going back to his/her primary care provider for continuing asthma care. Before placing the call, the clinical case manager reviews the child’s medical history, asthma triggers, environmental exposure, medications, Asthma Action Plan, and social/psychological issues. The clinical case manager reviews the case management care plan for specific problems, goals, interventions, and timelines. The clinical case manager’s objectives for the clinical assessment call are to:

• address any questions or concerns the family may have about asthma or challenges they may be facing
• assess current asthma control by reviewing peak flow numbers, frequency of symptoms, beta agonist use, and activity limitations
• if asthma control has not been achieved, assess the child’s self-management skills and try to determine the causative factors. (The Telephone Assessment Protocol contains a set of questions to ask the parent in order to help the clinical case manager determine why the child’s asthma is not under control: not taking medications, not using them correctly, inadequate environmental control, presence of viral infections, allergic rhinitis, sinusitis, family not understanding the Asthma Action Plan, and so on.)
• assess the family’s readiness to make needed behavior changes that will lead to improved disease control. If the family is ready, the clinical case manager helps caregivers identify realistic solutions to the problems and helps them to set goals to successfully accomplish needed changes.
• assess the caregiver’s confidence in his or her own ability to manage the child’s asthma
• review the Asthma Action Plan with the caregiver
• summarize agreements and next steps with the caregiver

Following the assessment call, the clinical case manager consults with the clinician about the need for medication changes or adjustments, creates a new Asthma Action Plan if needed, arranges for any needed medication refills or equipment, and sends a reminder to the family about the next clinic visit and telephone follow-up call.

During the second clinic visit, the CHW meets the family and follows up on their progress on reaching the goals set at the home visit. The CHW discusses what will occur during the second clinic visit and how long the visit will take. The CHW answers questions about the program or the visit and provides information as needed.

The clinical case manager measures peak flow and spirometry in children aged 5 years and older and administers 2–4 puffs of albuterol as ordered by the clinician. The clinical case manager meets with each child and family to discuss issues and concerns and assess the status of the child’s asthma. If the asthma is not controlled, the clinical case manager explores reasons and works with the family to set goals for improved control. The clinical case manager then assesses self-management skills and provides information on self-management as needed. After 20 minutes, the post-bronchodilator spirometry is administered.

The clinician reviews the child’s records, performs a physical assessment, and interprets the spirometry results. The clinician does a reassessment of asthma control and initiates or makes adjustments to the medications and the Asthma Action Plan as needed. The clinician provides the prescriptions for new medications, metered dose inhalers, and spacers as needed.

The CHW schedules the next home visit, if needed, and also schedules the next asthma clinic visit. The CHW answers questions about self-management and the asthma program, and discusses the next steps for any urgent psychosocial needs the family has identified.

Following the second (and any subsequent clinic visits) the clinical case manager makes clinical assessment telephone calls to the family to answer any questions or concerns the family may have and to assess the status of asthma control. The clinical case manager encourages the caregiver to sustain asthma self-management behaviors and recognizes accomplishments achieved. If self-management is not working, the clinical case manager probes to understand the problems and provides counsel and support to the caregiver as needed. They review the Asthma Action Plan together and resolve problems associated with adherence with medications. Succeeding asthma clinic visits and additional clinical assessment phone calls follow the same process that was described previously in this report. Flow Chart 2 [opens in new window] shows how a typical patient would go through a return asthma clinic visit.

During the follow-up visit to the child’s home, the CHW conducts a self-management education review, a medication review, and an Asthma Action Plan review. The CHW encourages the family and elicits and responds to patient and family questions. The child is asked to demonstrate how he/she takes the medications. A primary objective of this, visit and subsequent visits is to follow up on recommendations made during the first visit to reduce asthma triggers in the home and to encourage and assist families as needed. Another objective is to follow up on referrals and family concerns.

For subsequent clinic visits, the clinician and the clinical case manager follow the same protocols as in the second visit. When the results of the clinic visit show that the child’s asthma is under control and the family is practicing good asthma self-management, the clinician and the clinical case manager determine that, from a medical standpoint, the child can be returned to primary care. Indications of good asthma control are defined in the program as:

1. minimal (if any) chronic symptoms, including nocturnal symptoms less frequently than twice a month
2. infrequent exacerbations
3. minimal need for bronchodilators (less than two times a week)
4. no limitations on activities, including exercise
5. peak expiratory flow is consistently greater than or equal to 80% (optimally 90%) of personal best
6. minimal, if any, adverse effects from asthma medicines

Families demonstrate good self-management skills when they understand

1. personal asthma triggers and how to avoid them
2. correct inhaler and spacer techniques
3. how to measure peak flow
4. how to use medications correctly
5. how to recognize an asthma flare-up
6. how to adjust medications during an asthma flare-up
7. have systems in place to effectively manage asthma, for example, Asthma Action Plan posted and use of medication/equipment boxes.

Criteria for closure of care management by the asthma clinic also includes a social evaluation that considers the following questions.

1. Does the child have insurance coverage?
2. Does the family have a primary care provider?
3. Does the family have an Asthma Action Plan, prescribed medications, and equipment on hand?

When the criteria are met and the answers to the social questions are affirmative, the decision is made to return the child to primary care, and the family is so informed. The clinical case manager coordinates the transition from asthma clinic care back to enhanced primary care. If either the health criteria or the social criteria are not met, the child continues care in the asthma clinic until such time as these criteria are met.

Flow Chart 3 [opens in new window] depicts the operation of the four levels of care in the program. Children with the greatest need receive the greatest amount of clinical, environmental, and social care. The flow chart also demonstrates the sequencing of interventions between clinical visits, home visits, and clinical assessment phone calls. The interventions continue until the child’s asthma is shown to be under control, the family demonstrates good self-management skills, and the family has acquired primary care, health insurance, and access to asthma medications and prevention supplies.

Chronic conditions such as asthma require day-to-day self-management that can be time consuming and inconvenient. To help patients make health behavior changes, the instruction is designed to foster patient self-efficacy or confidence to apply the knowledge and skills routinely each day. Instruction also emphasizes patient and caregiver skills and the demonstration of those skills to verify the child’s ability to properly use the MDI, spacer, and peak flow meter, and the caregiver’s ability to properly use the Asthma Action Plan.

The instruction mirrors the active partnership philosophy established and maintained between the asthma team and the caregiver and child. The asthma team recognizes that the child and the family are the primary asthma care providers. Whereas the health care professionals are experts on asthma, the family is the expert on fitting asthma self-management into their daily life. The asthma team supports the family in this role, and health care decisions are made together. Caregivers are prompted to discuss the impact of asthma on the family and on the child’s activities and emotions, and to discuss the challenges and barriers faced in managing the child’s asthma day after day. Education is part of the team effort to help the family define their desired outcomes and actions needed to achieve those outcomes.

Education is tailored to each family. Tailoring education saves time, makes the encounter more effective, and improves family satisfaction with the care. Factors considered when tailoring the education include:

• current asthma knowledge and skill levels
• cultural background
• language
• educational level
• literacy level
• learning disabilities
• readiness to learn
• level of "life skills"
• coping abilities
• psychosocial issues

Acquiring knowledge and understanding and applying skills related to the learning takes time. Asthma self-management education requires behavior changes on the part of the child (primarily medication adherence) and the family (primarily changing environmental conditions in the home). Encouragement for the learners and reinforcement of key behaviors are important to the family and the child’s ability to sustain behavior changes. Repetition of key learning points, review of patient knowledge and understanding, skill demonstrations, and feedback are all required to ensure that the patient and caregiver fully grasp and internalize the educational messages. Every member of the asthma team takes part in promoting self-management education. Although the clinical case manager has overall responsibility, the CHW and the clinician instruct, review, and reinforce learning whenever they are in contact with the family. Checklists and other job aids are used to guide the review process.

The goal of the asthma education lessons is to provide consistent, evidence-based patient education that is presented efficiently, effectively, and in an interactive manner. Each lesson conforms to a common format that includes:

• guideline information comprised of key points and recommendations for each topic
• key messages for the child and the family
• strategies for interactively delivering the key messages
• resources, handouts, visual aids, patient educational materials.

Asthma education lessons

There are 18 asthma education lessons. Lesson titles include:

• What Is Asthma?
• Long-Term Control Medications–Inhaled Corticosteroids
• Long-Term Control Medications–Long–Acting Bronchodilator
• Long-Term Control Medications–Long–Action Bronchodilator: Theophylline
• Long-Term Control Medications–Leukotriene Receptor Antagonists
• Long-Term Control Medications-Cromolyn Sodium and Nedocromil Sodium
• Quick-Relief Medication: Albuterol
• Quick-Relief Medications: Anticholinergics
  The family receives instruction on the asthma medications prescribed for
  their child.
• Peak Flow and Symptom Monitoring
• Finding the Personal Best Peak Flow
• Understanding Asthma Action Plans
• Correct Use of MDI and Spacer Devices
• Correct Use of a Dry Powder Inhaler
• Medication: Reading Prescription Labels and Getting Results
• Medication: Tracking Puffs in a Canister
• Identifying and Controlling Asthma Triggers
• Recognizing and Managing Severe Asthma Episodes
• Physical Activity: Exercise and Asthma

The YES WE CAN asthma team addresses both the medical and psychosocial aspects of asthma that are characteristic within this sub population. The CHWs’ involvement in the clinic activities (orientation, education, home visits) brings them face to face with patient families early in the intervention. The CHWs come from the communities they serve, and they are trained in cultivating trust. Minority patients and their families identify with the CHWs who share the same ethnic heritage and language. This interaction between the CHWs and the families improves program credibility among those being served. The CHWs are the connectors between clinic staff and patients, serving as the clinicians’ eyes and ears. The CHWs learn what is going on with asthma management at the patient’s home (for example, whether the patient is not taking medications or the environmental conditions at home are deplorable), and they report this back to the team so these issues can be addressed and resolved. According to cofounder and director of the program, Vicki Legion, "The asthma team’s medical/social approach allows the intervention to walk with two legs. Medical care and social assistance must be married because even the best medical regimen will not work if families have social complications. Program effectiveness is greatly enhanced by the three member team approach." Dr. Antonia Sacchetti, Medical Director of the Mission Neighborhood Health Center, praises the work of the CHW on the asthma team. "The doctors here know that the program could not obtain the health outcomes it does without the CHW. The CHW is indispensable to this program."

The YES WE CAN clinical care system that targets high-risk children delivers care through a multidisciplinary team, employs feedback loops and close care management, and promotes asthma self-management. It has proven to be successful in the chronic condition management model pioneered in Northern California by Kaiser Permanente. The YES WE CAN leadership enriched the newly adopted program with the introduction of the CHW into the team, and then applied this hybrid asthma care system to the neediest segment of the population, inner-city minority children. The YES WE CAN directors also incorporated recommendations and suggestions from KP/NC chronic condition management leaders as it launched the demonstration project. Subsequent health outcome data from YES WE CAN patients and their families who have completed the program over the years has further proven the effectiveness of this approach to asthma care.

Since 1997, rates of hospitalizations for asthma have fallen 21.1% and ED visits for asthma have fallen 48.8 % among KP patients on average among all eight KP/NC regions of the country (Testimony before the Subcommittee on Health of the House Committee on Ways and Means, March 18, 2004, by Dr. Francis J. Crosson, Executive Director, The Permanente Federation, Kaiser Permanente). This record suggests that the YES WE CAN program can be successfully replicated in other communities with similar positive results.

Holding asthma team case conferences regularly at the end of each clinic day, as initially projected, was a challenge that could not be overcome. The difficulty was finding the time when all three asthma team members could meet together at the end of clinic. Often the clinical case manager and the CHW met together to discuss the cases, but the clinician was not always present. At times, any one or more of the asthma team were faced with conflicting priories that prevented the case conference from occurring. The solution was to reduce the number of case conferences each week to one. These meetings are often held on Fridays at the end of the week or in the afternoon of the last clinic day of the week. During this one sitting, the asthma team reviews all the cases of patients who visited the clinic during the week so they can develop or revise care plans for each patient as needed.

Some families do not understand that once their child’s asthma is under control, the family demonstrates it can manage the child’s asthma, and the child has graduated from YES WE CAN, they are to return to their primary care physicians for continuing asthma care and prescriptions. The YES WE CAN experience is such a positive one for some families that they want to continue receiving asthma care for the child at the clinic instead of returning to their primary care provider. When they need more asthma medications or consultation, they continue to call on the clinic. Some families have become quite attached to their CHW and continue to call on them for assistance. Weaning these families away from continued dependence on the YES WE CAN clinics and the CHWs is an ongoing challenge. Repeated explanations of this "graduation process" will help families better prepare for and accept the return to mainstream care.

In the initial YES WE CAN demonstration program, all families were required to accept home visits. Experience made it clear, however, that not all families benefited from home visits. There was not always a need for social help, improvements in environmental controls, or asthma self-management reinforcement. Also, some families who agreed to have home visits did not follow through to complete all their visits. The conclusion reached was that home visits were not always the best use of the CHW’s time. As a result, families are no longer required to accept home visits to be enrolled in the program.

YES WE CAN has always preferred to conduct patient and family asthma educational activities at the point of care. In the initial demonstration project, the clinical case manager conducted the family educational program during the clinic visits. The CHW’s job was to reinforce in the home the learning gained at the clinic. Experience showed that involving the CHWs more with the families early on in the clinic improved the asthma team’s rapport with the family and better prepared the family to later receive the CHW in the home. Having the CHW deliver the initial asthma care instruction in the clinic also freed up the clinical case manager’s time for other tasks. Now CHWs routinely conduct the education program. This program change has also strengthened the "team" concept of asthma care.

In the early days of the project, acquiring asthma-prevention supplies (spacers, peak flow meters, mattress and pillow covers) was difficult and haphazard. Although these items were always available to the YES WE CAN clinic, there was no system in place for routinely transporting them from the provider to the clinic. Often, a CHW would have travel across town at the last minute to pick up supplies for the clinic. Now, the asthma prevention supplies are gathered up each month by a delivery service from the Medi-Cal managed care plan provider and delivered to the clinics on a regular schedule.

Inadequate tracking and monitoring of patients caused inefficiencies in the program and resulted in diminished effectiveness and unnecessary costs. Some children did not complete their asthma treatment program and were lost to the program. Some children who completed the program kept coming back to the clinic for asthma care, instead of returning to their primary care provider at the conclusion of the intensive intervention. Others made too many unnecessary visits while in the program. Better monitoring of progress along the care pathway was needed. The introduction of the asthma registry patient database and improvements in caseload monitoring helped solve these problems. Enrolled children are no longer dropping off the care pathway and becoming lost to the program. Improved caseload monitoring helps control the number of visits a child may have and aids in transitioning families back to their primary care provider.

In the beginning of the demonstration project, the clinical and home visit protocols lacked the necessary detail to ensure consistency, reliability, and repeatability. Further, without the written descriptions of each asthma team member’s duties and responsibilities, the explanation of how the medical/ social model of care operates, knowledge of the protocols, and how to apply risk in assigning care, the probability of YES WE CAN being successfully replicated anywhere else was greatly reduced. Between 2001 and 2003 Community Health Works and KP/NC staff members worked tirelessly to systematize the processes and supply supporting instruction, along with checklists and job aids to guide the processes. The protocols are all now codified into three manuals called the YES WE CAN Toolkit.

In the planning phase of the project, it is a good idea to put in place an interdisciplinary oversight group that can act as a steering committee for the program. Members of the group should be the organizational decision makers. The oversight group will likely be comprised of leaders from the founding organizations and leaders representing stakeholders in the community. The primary founding organization for the asthma program also needs strong leadership support from its own top management.

Grants are good sources of funding to launch a community-based asthma program; however, it is not wise to rely on grant money to fund the long-term operation of the program. Other more sustainable funds are needed so that the program is not dependent on any single funding source for survival.

For the program to be successful, it must have buy-in from the primary care providers in the area and other medical groups who will provide patient referrals. Program directors and asthma champions pioneering this program in new areas will have to make program presentations in the community and look for opportunities to seek buy-in from these groups of medical professionals.

It is likely that a new program will not run smoothly as soon as it starts, but with lots of work, a clinic can be up and running in 90 days. It may take 6 months to be fully functional and efficient (considering staffing and training, setting up facilities and a patient registry, establishing protocols and learning the asthma-education routines, and obtaining equipment and supplies including computers, cell phones, telephones, desks, and bookshelves).

It can be helpful to carry out a dry run or a mini-drill of the clinic and to think through, and then actually walk through, the entire process from start to finish. Such practice helps assure that everyone knows and understands the protocols to follow, and how and why they fit together. It may be prudent to conduct a dry run for the clinic more than once.

Mutual respect among all the asthma team members is an essential requirement for success of the program. In the triumvirate that comprises the team, two of its members, the clinician and the clinical case manager, are recognized health professionals. The CHWs’ education and work experience is dissimilar. There may be a tendency among the medically trained team members to interact differently with the CHW than with each other. The CHWs must be fully integrated into the team if the team is to have strength and function smoothly. The program will need strong supervision and time for the team to gel and integrate the CHW into the clinical setting.

• A 30-month old African American boy living in public housing with his single mother was in urgent care in December 2003 with severe persistent asthma. The allergy skin prick test showed the boy to be allergic to egg whites, soy, and oranges in addition to mold, dogs, cats, and Arizona Cypress trees. The mother learned to administer medications as prescribed and to decrease the child’s exposure to potential triggers. The child exhibited no symptoms in early March 2004.
   
• A 10-year-old Latina girl experienced numerous asthma episodes, primarily exercise-induced, prior to enrolling in YES WE CAN. After graduating from the program, she is fully active in sports and her symptoms are under control.
   
• A 5-year-old Latina girl in kindergarten experienced several asthma episodes associated with upper respiratory infections. Appropriate medications, the avoidance of triggers, and a flu shot ended the episodes for the child. The mother reports that her daughter’s asthma is much better controlled as they follow the asthma program.
   
• An 11-year-old Latino boy experienced numerous ED visits and a hospital stay for asthma before being referred to YES WE CAN. The boy is allergic to dog and cat dander, pollen and grasses, dust mites, and cypress trees and is affected by changes in the weather. Adherence to the medications and a change to a more environmentally healthy residence have resulted in improved asthma control.
   
• A 6-year-old Latino boy and his 2-year-old sister were both frequently sick with asthma. They were allergic to mold, pollen, dust mites, grass pollen, and cypress trees. The 2-year-old was also admitted to the hospital with asthma in late 2003. Strict adherence to the prescribed asthma medication procedures and some remedial environmental actions in the home (mold removal, use of mite-impermeable mattress and pillow covers) have resulted in both children being free of serious illness from asthma since being enrolled in YES WE CAN.

• An undocumented Latino immigrant family had a 4-year-old boy with asthma. The SFGH records showed the child had three ED visits in frequent succession; all billing records indicated diagnoses of pneumonia. The boy also visited the ED another 13 times for asthma and 4 additional times for upper respiratory infections. Finally, in March of 2002, the child was hospitalized for four days with pneumonia. The family had refused any home visits because they worried about being reported to the immigration authorities. However, later that same year, the boy was scheduled for a visit to the YES WE CAN asthma clinic at SFGH. The child maintained monthly check-ups with the clinic. The family finally agreed to a home visit following the visit to the clinic. The home visits revealed the presence of an old carpet. The CHW recommended carpet removal and helped the family write a letter in English to the landlord requesting removal of the carpet. This request was followed up with a similar request letter from the YES WE CAN clinician. The carpet was removed and the child, on the appropriate asthma medications, improved dramatically. By early fall of 2003, the child met all criteria for graduation from the YES WE CAN program.
   
• A 2-year-old Latina girl was admitted to the hospital in October 2003 for a 3-day stay. The child’s diagnosis included pneumonia and a positive culture for respiratory syncytial virus, common in young children with asthma. During the hospitalization, the inpatient medical staff did not formally diagnose the child, and she was sent home with only albuterol and a spacer. A medical resident on the inpatient floor alerted staff in the YES WE CAN asthma clinic about the girl. The family was referred to the CHW for a home visit in October 2003. The CHW learned that the family was on a 4-month waiting list for a specialty asthma clinic appointment and was looking for more affordable housing. The family lacked medical insurance, but wanted to get help for their child. A YES WE CAN clinic appointment was not available until late December 2003. In early December, however, the child visited the Urgent Care Center at SFGH with severe asthma symptoms, and was admitted to the hospital for three days. A medical resident called the YES WE CAN asthma clinic. The child was scheduled for an emergency clinic appointment the day of her discharge from the hospital. The child was prescribed both a controller medication and rescue medication. The family and the child were instructed on proper use of the medications, and the child’s symptoms soon subsided. At the local housing clinic, the family was given a referral for housing. They were able to relocate to a larger, sunnier, less humid, noncarpeted, and more affordable apartment in San Mateo County.
   
• An African American family living in public housing had a 6-year-old child who had asthma. Mold and mildew growth covered part of the ceiling and walls in the kitchen and the living room closet of the family’s home. The CHW wrote a letter to the San Francisco Housing Authority on behalf of the family, describing the mold and mildew conditions that were detrimental to the child’s health. The housing authority conducted an inspection and agreed to make repairs, including repairing the roof, cleaning the moldy areas, and repainting the affected rooms. These actions stopped the leaks, eradicated the mold, and reduced the boy’s asthma symptoms.
   
• A Latino family lived in substandard housing in the Mission district with two children with asthma; a boy aged 11 years and a girl aged 5 years. Environmental problems in the apartment included mold on the bedroom walls and ceiling. There were leaks in the roof, dampness in the living room area, and old carpeting. The family’s requests for repairs just brought harassment from the landlord. The mother shared her frustrations about the housing conditions with the CHW. The CHW first helped the mother fill out an application for low-income housing. However, the mother rejected the housing offered because she feared the neighborhood was not safe for her children. So, the CHW helped the mother complete a housing lottery form that offered a chance of being awarded a new apartment. To everyone’s surprise, the family won the lottery and was awarded a three-bedroom apartment, part of a large new complex. The children’s asthma is under control, and the family is delighted with their new dwelling.
   
• In another case, a single Latina mother with a 5-year-old girl with asthma lived in a single room with deplorable living conditions. Seven families shared a single shower, a single water closet, and a single kitchen. There was a hole in the kitchen window big enough for a basketball to pass through. Filth and clutter were everywhere. The CHW helped the mother complete an application for a new dwelling to be awarded through the housing lottery program. The woman has won the lottery and is waiting for the dwelling to be completed.
   
• A CHW delivered self-management education in the clinic for a parent of a child with asthma who lived with her family of four in a small single room. The CHW visited, telephoned, and kept in communication with the mother. She provided the woman a referral for public housing. Another family with a child with asthma was allergic to feathers, yet the family had several birds in the home. The CHW convinced the family to find another home for the birds. Eliminating the feathered animals from the home and adhering to the medication regimen helped improve the child’s asthma symptoms.

Six families enrolled in YES WE CAN were visited in their homes in March 2004 to learn firsthand their experiences with the asthma program and to record some of their observations and comments about the program. The case study investigator was accompanied by the CHW who had worked with the family and was familiar with their circumstances. In each instance, the parent was asked questions from a prepared set of interview questions that addressed (1) enrollment in the program, (2) what the family learned about asthma they did not know before attending clinic, (3) what took place in the home regarding environmental changes and removal of social barriers to asthma care, and (4) changes in the child’s asthma symptoms.

Enrollment in the Program
All of the families reported that they were able to enroll in the YES WE CAN asthma clinic without difficulty. In each instance the family had been referred to the program. Clinicians at pediatric clinics referred four of the families, and the ED referred one family following their child’s visit for asthma. Another family was referred by the hospital after their child was admitted to the hospital because of asthma. In all instances, the families accepted the clinical services, the home visits, and the social assistance offered in their home.

What the family learned about asthma
The families reported that in other healthcare settings they failed to gain sufficient knowledge about their child’s asthma to know what was happening. Confused, upset and uninformed, they just struggled on without the tools to really make a change in the child’s condition. In some instances, the child was given an inhaler and sent home. Over and over again, families reported that the YES WE CAN staff took the time to explain things to them. Caregivers reported that they learned about inflammation in the lungs, they learned about things that trigger asthma episodes in their child, and they learned about the medications and how to administer them. They also learned how to use the Asthma Action Plan. A couple of families just laughed when asked if the asthma knowledge they received at the clinic was ever reviewed and reinforced later. "We get some of it on every visit to the clinic and every time the CHW comes to the home." This increase in knowledge and skill has made caregivers feel more comfortable dealing with their child’s asthma.

What environmental changes and removal of social barriers took place
Whereas most of the families did not discuss a formal environmental assessment carried out with the CHW, each family did talk freely about changes that were made to improve their child’s condition. Several mentioned that they received mattress and pillow covers for the child’s bed, which they installed. Removal of stuffed animals and other items that cause dust from the child’s room, cleaning mildew and mold, and having minor repairs made were mentioned two or more times. Other items that caregivers mentioned that could impact a child’s asthma were learning how to

• wash the bedding to kill dust mites
• obtain needed asthma medications
• fix a bathroom leak to rectify a mold problem
• obtain health insurance.

One of the caregivers, a single father raising a 10-year-old daughter with asthma, said that he needed to be prepared to deal with the child’s condition. He confessed that he was not prepared and that not being prepared was the worst feeling. "The instruction and information received at YES WE CAN was the greatest. We have only good things to say about it, the results really tell us it works. Marisol now plays sports; she runs, and her symptoms are down. The program is wonderful. Yes, it saved my child’s life."

• Volume One: Program Implementation Manual (350 pages)
  1. Introduction
  2. Population Management
  3. The YES WE CAN Medical/Social Model
  4. Getting Started
  5. Program Monitoring
  6. Creating an Asthma Registry
  7. Staffing: Roles, Caseload and Job Descriptions
  8. Staff Training and Management
  9. Operational Issues
  10. Community Partnerships and Coalitions
  11. Implementation Checklist
  12. Power Point Demonstration
  13. Professional Resources
       
• Volume Two: Clinical Care Manager Manual (434 pages)
  1. Introduction
  2. Population Management
  3. YES WE CAN Medical/Social Mode
  4. Referral and Outreach Process
  5. YES WE CAN Pathway
  6. Asthma Clinic
  7. Home Visit
  8. Telephone Assessment Calls
  9. Program Exit
  10. Case Management
  11. Self-Management Education
  12. Promoting Behavior Change
  13. Caring For a Diverse Population
  14. Operational Issues
  15. Sample Forms, Letters, Handouts, and Brochures
  16. Professional Resources
      
      
• Volume Three: Community Health Worker Manual (869 pages) – available in English and Spanish editions
  1. Introduction
  2. What is Asthma: Asthma and Your Body
  3. Asthma and Your Community
  4. Asthma and Your People Skills
  5. Working With families
  6. Resources: Know What To Do
  7. Check What You Know