CDC - Asthma - Interventions - YES WE CAN Children’s Asthma Program

Flow Chart 3: YES WE CAN Care Paths

Asthma Clinic Visit 1

Level 1 ^(a)	Level 2 ^(b)	Level 3 ^(c)	Level 4 ^(d)

	Home visit 1 by CHW (1 to 2 weeks later)	Home visit 1 by CHW (1 to 2 weeks later)

	Clinical assessment call 1 by CCM	Clinical assessment call 1 by CCM	Co-Managed Care ^(e)

	Asthma clinic visit 2	Asthma clinic visit 2

	Home visit 2 by CHW (optional)	Home visit 2 by CHW (1 to 2 weeks later)	Clinic and home visits continue until such time as the child's asthma is under control

	Clinical assessment call 2 by CCM	Clinical assessment call 2 by CCM

	Clinical assessment call 3 by CCM	Home visit 3 by CHW (optional)

	Closure: Asthma assessment visit	Clinical assessment call 3 by CCM

		Closure: Asthma assessment visit

Return to Enhanced Primary Care Routine asthma follow-up visits (at least yearly) Ongoing self-management education and support Use of written Asthma Action Plans Rapid intervention if adverse event		Criteria for Closure of Care Management Clinical Asthma is controlled and Family demonstrates ability to self-manage Social Child has insurance care coverage Family has primary care provider Family has Asthma Action Plan, prescribed meds, and equipment

(a) Level 1: Self-management support. Child with relatively well controlled asthma. Family has self-management skills. Relatively stable social/psychological status.

(b) Level 2: Basic care management. Child with poor asthma control. Family needs self-management skills. Relatively stable social/psychosocial status.

(c) Level 3: Moderate care management. Child with poor management control. Family needs self-management skills. Moderately complex social/psychosocial issues.

(d) Level 4: Intensive care management. Child with poor asthma control. Family needs self-management skills. Highly complex social/psychosocial issues.

(e) Co-managed care: Care is co-managed. Clinic and home visits continue until such time as the child's asthma is under control.

Expert asthma management by specialist (allergist, pulmonologist or other)
Other specialists
Primary care provider
Multidisciplinary tam (mental health worker, social worker, etc.)
YES WE CAN team consultation

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Flow Chart 3: YES WE CAN Care Paths

Asthma Clinic Visit 1

Level 1 (a)

Level 2 (b)

Level 3 (c)

Level 4 (d)

Home visit 1 by CHW (1 to 2 weeks later)

Home visit 1 by CHW (1 to 2 weeks later)

Clinical assessment call 1 by CCM

Clinical assessment call 1 by CCM

Co-Managed Care (e)

Asthma clinic visit 2

Asthma clinic visit 2

Home visit 2 by CHW (optional)

Home visit 2 by CHW (1 to 2 weeks later)

Clinic and home visits continue until such time as the child's asthma is under control

Clinical assessment call 2 by CCM

Clinical assessment call 2 by CCM

Clinical assessment call 3 by CCM

Home visit 3 by CHW (optional)

Closure: Asthma assessment visit

Clinical assessment call 3 by CCM

Closure: Asthma assessment visit

Return to Enhanced Primary Care

Criteria for Closure of Care Management

Level 1 ^(a)

Level 2 ^(b)

Level 3 ^(c)

Level 4 ^(d)

Co-Managed
Care ^(e)