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Area 1: Comprehensive Asthma Management Program

Award Criteria » Application Guidelines and Evaluation Criteria for Communities in Action » Area 1: Comprehensive Asthma Management Program

This section is comprised of three components which are designed to capture your organization’s contribution to delivery of comprehensive asthma services in your community.  (1.a) As well as gain an understanding of the integrated health care services (1.b), and tailored environmental interventions (1.c) your program and your partners provide. Highlight high-performing collaborations that contribute to your success, and discuss your approach to reducing asthma disparities in the community you serve.

1.a Management Structure and Operating Principles (20 points)

Tell the story of how your program:

  • Came into existence and what leaders emerged as champions for your program and your partners;
  • Established a dynamic organizational framework to manage its various elements and your role within the management of the organization;

And how your program and your partners continue to:

  • Assess and address your target community’s needs, as well as identify goals aligned with those needs;
  • Foster high-performing collaborations to achieve success; and
  • Maintain strong community ties.
Application Guidelines Evaluation Criteria
  • What need did you or your partners recognize in your community and how did you initially plan to address those needs (e.g., who championed your effort, what other organizations did you partner with, etc.)?
  • Discuss your program's or partners' goals and how they aligned with the needs of your community's asthma population.
  • Describe how your program and your partners identify the population disproportionately impacted by asthma and connect them to asthma services. State the percentage of your community's asthma population you reach.
  • Describe the organizational structure including the coordination, management or administrative roles within your program and your partners.
  • Describe how your program engages community stakeholders and partners in planning and implementing your program as well as how you ensure that your program continues to reflect your community’s needs. For example, explain how you effectively target disproportionately impacted or underserved populations.
  • Discuss how your program and your partners make services accessible to people with asthma.
  • The applicant identified and encouraged leaders and champions who helped to establish, build and promote the program and partners.
  • High-performing collaborations and partnerships help to achieve the program's and partners' goals, gain credibility within the target community, ensure the delivery of services, and leverage resources.
    • Example: Distinguishing Program Feature: A health department developed a local, regional and state/territory-wide Asthma Plan with their partners, enabling stakeholders to use a state-supported platform for planning and implementing their asthma activities.
  • Program and partners' goals and strategy are comprehensive and are aligned with the community's asthma services needs.
    • Example: Distinguishing Program Feature: Advocacy efforts aimed at creating asthma-friendly environments (e.g., support for local or state laws limiting exposure to secondhand smoke).
  • The applicant’s coordination and oversight of the program and partners is critical to the effective delivery of asthma services in the community.
  • The program or partners continually assess and refine its service offerings and delivery based on feedback from the target community and takes action to continuously ensure strong community ties (e.g., participating in local organizations and activities, hiring from the local community, and including community stakeholders in program planning and implementation).
    • Example: Distinguishing Program Feature: The program effectively targets disproportionately-impacted or disparate populations (e.g., providing underserved communities access to services).
    • Example: Distinguishing Program Feature: A health department engaged diverse communities across the state/territory (or region) through contracts, pilot programs and/or grants awarded to community health centers, county health departments or other partners, etc.
  • The program and partners make services accessible to its target community and employs approaches to increase participation in programs (e.g., targeted outreach, incentives for participation in program components, accessible office locations and hours).
    • Example: Distinguishing Program Feature: Effective community engagement that raises awareness of the program to increase or improve participation.
  • School-Based Asthma Management Programs:
    • Example: Distinguishing Program Feature: Identifies and collaborates with a diverse set of partners to improve asthma management in schools.
    • Example: Distinguishing Program Feature: Works with the community to increase awareness about asthma’s impact on students and how to effectively control it.
    • Example: Distinguishing Program Feature: Understands the connection between effective asthma management in schools and healthy learning environments.
    • Example: Distinguishing Program Feature: Demonstrates results in improved academic performance based on asthma control strategies implemented in the school.

1.b Integrated Health Care Services (20 points)

Describe the elements of your program and briefly explain how you and/or your partners promote integrated health care services that incorporate the NIH EPR-3 Guidelines throughout the continuum of care.

Application Guidelines Evaluation Criteria
  • Describe how you or your partners train care providers on the NIH EPR-3 Guidelines.
  • Explain how your partners responsible for the delivery of asthma services and education promote and incorporate the NIH EPR-3 Guidelines throughout the continuum of care (e.g., assessing asthma severity to determine initial therapy, continually assessing the level of asthma control and adjust therapy as necessary, scheduling follow-up care selecting medication and delivery devices to meet the needs of the population disproportionately impacted by asthma, and providing education as a component of every interaction with persons living with asthma).
  • Describe your program’s approaches to support case management and self management.
  • Discuss the mechanisms you or your partners have in place to ensure effective and timely communication and collaboration among multidisciplinary teams (e.g., health care providers and community partners) responsible for providing asthma services.
  • Integrated health care services are comprehensive and incorporation of the NIH EPR-3 Guidelines throughout the continuum of care are promoted. Your partners responsible for delivery of asthma services and education:
    • Assess asthma severity to initiate therapy;
    • Assess asthma control to monitor and adjust therapy;
    • Provide self-management education and encourage use of asthma action plans; and
    • Integrate education into all points of care where health professionals interact with persons living with asthma.
    • Example: Distinguishing Program Feature: Education, reimbursement or incentive programs that effectively engage health care partners in delivering care consistent with the NIH EPR-3 Guidelines.
    • Example: Distinguishing Program Feature: Education materials and approaches are customized to be culturally appropriate and meet specific needs of the target audience.
  • Mechanisms to ensure effective and timely communication and collaboration among multidisciplinary teams (e.g., primary care physicians, specialists, case managers, community partners) responsible for providing asthma services throughout the continuum of care.
    • Example: Distinguishing Program Feature: Health departments coordinate with Medicaid to ensure incorporation of chronic care model into delivery of asthma services.

1.c Tailored Environmental Services (30 points)

Describe the elements of the environmental component of your program, addressing both indoor and outdoor environmental triggers. Explain how you ensure that your partners integrate environmental services throughout the continuum of asthma care services.

Application Guidelines Evaluation Criteria
  • Identify which of your partners are responsible for implementing the environmental components of your community asthma program. Discuss who (e.g., primary care, specialists, case managers, respiratory therapists, community health workers) delivers different asthma care services.
  • Discuss how your program and/or your partners tailor environmental services to address community needs.
  • Discuss education and counseling services that your asthma program and your partners provide to persons living with asthma and their families regarding environmental triggers and self-management, including who receives these services, the reach of the services (number or percent of the asthma population reached), how frequently and under what circumstances or conditions (e.g., whether the frequency depends on asthma severity and control), how (e.g., in person, online, in clinical settings), and by whom.
  • Discuss education on environmental management your program and your partners provide to health care providers, including who receives training, the reach of the services (number or percent reached), how frequently and under what circumstances or conditions (e.g., whether education is offered only to new staff), how (e.g., in person, online, in the provider’s office), and by whom.
  • Describe tools and materials (e.g., mattress and pillow cases, pest control devices, home cleaning supplies) you or your partners provide to help persons living with asthma manage their environmental triggers.
  • Describe tools and materials distributed to your asthma program’s or your partners’ health care providers to support their clinical decision making regarding environmental management of asthma (e.g., flip charts, electronic guidelines, or other diagnostic and treatment aids).
  • Describe your asthma program’s or your partners’ home-centered environmental management services, including who receives services, the reach of the services (number or percent of the asthma population reached), how frequently and under what circumstances or conditions (e.g., whether the frequency depends on asthma severity and control), what services are provided, and by whom.
  • Describe your program’s or your partners’ school-, daycare-, and employer-centered environmental management services, the reach of the services (number or percent of the asthma population reached or number or percent of facilities affected), how frequently and under what circumstances or conditions (e.g., whether services are regularly scheduled or on a special request basis), how (e.g., at the employer’s site or in your facilities), and by whom.
  • Discuss mechanisms (e.g., case management to coordinate the delivery of asthma care services) you or your partners have implemented to ensure that health care professionals receive feedback regarding measures taken to manage indoor and outdoor environmental triggers.
  • Elements of environmental management are addressed throughout the continuum of care.
  • Education and outreach programs aimed at persons living with asthma address indoor and outdoor environmental triggers and their management.
    • Example: Distinguishing Program Feature: Effective use of incentives to ensure participation by persons living with asthma.
  • Multi-faceted allergen control interventions address environmental management of asthma at home and in other settings (e.g., school and work) where persons living with asthma spend time. Interventions may include home visits, durable equipment, asthma counseling (including smoking cessation), or social service referrals.
    • Example: Distinguishing Program Feature: Established school-, daycare-, and employer-centered environmental management programs.
  • Persons living with asthma are identified, their sensitivity to indoor and outdoor environmental triggers is assessed, and environmental interventions are tailored accordingly.
    • Example: Distinguishing Program Feature: A health department actively coordinates with state Medicaid to secure reimbursement for environmental trigger reduction activities and education materials.
  • Health care professionals responsible for treatingasthma are trained to ensure that they are knowledgeable about environmental triggers and their management.
  • Health care professionals responsible for treating asthma receive feedback regarding measures taken to manage exposure to indoor and outdoor environmental triggers.
  • High-performing collaborations and partnerships help to ensure delivery of tailored environmental services.
    • Example: Distinguishing Program Feature: A health department hosted several statewide symposia and trainings on healthy housing bringing together asthma and health advocates, housing advocates, code enforcement professionals, healthcare professionals and property managers.
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