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Area 1: Comprehensive Asthma Management Program

Award Criteria » Application Guidelines and Evaluation Criteria for Health Care Providers » Area 1: Comprehensive Asthma Management Program

In this section, describe your comprehensive asthma program, including your program’s management structure and operating principles (1.a) as well as the integrated health care services (1.b), and tailored environmental interventions (1.c) your asthma program provides. 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 asthma program:

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

And how your program continues to:

  • Assess and address your target community’s needs
  • Identify goals aligned with those needs;
  • Maintain strong community ties
Application GuidelinesEvaluation Criteria
  • Describe when and how your comprehensive asthma program came into existence. What need did you recognize in your community and how did you organize to address those needs (e.g., who championed your effort, what organizations did you partner with)?
  • Discuss your goals and how they are aligned with your community's health care needs.
  • Describe how you identify those in need of your care and enroll them in your program. State the percentage of your community's asthma population you reach.
  • Describe your organizational structure.
  • Describe how you engage community stakeholders in planning and implementation, 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 you make services accessible to people with asthma. Describe your approaches to increasing patient participation in your asthma program (e.g., outreach, patient incentives, pharmacy programs).
  • The applicant identified and encouraged leaders and champions who helped to establish, build and promote the asthma program.
  • High-performing collaborations and partnerships help to achieve the program’s goals, gain credibility within the target community, ensure delivery of services, and leverage resources.
    • Example: Distinguishing Program Feature: Partnerships with organizations that expand the program’s reach or depth within the community or bring new skills to the program.
  • Goals and strategy are comprehensive (i.e., address both medical and environmental management) and are aligned with the community’s asthma care needs.
    • Example: Distinguishing Program Feature: Advocacy efforts aimed at creating asthma - friendly environments (e.g., support for local laws limiting exposure to secondhand smoke).
  • The program continually assesses and refines 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).
  • The program makes services accessible to its target community and employs approaches to increase patient 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 patient participation.

1.b Integrated Health Care Services (20 points)

Describe the elements of your comprehensive asthma program and briefly explain how you ensure that the program delivers integrated health care services that incorporate the NIH EPR-3 Guidelines throughout the continuum of care.

Application GuidelinesEvaluation Criteria
  • Describe how you assess a patient's asthma severity to determine initial treatment, continually assess the patient's level of control and adjust therapy as necessary, schedule follow-up care, and select medication and delivery devices to meet the patient's needs and circumstances.
  • Discuss the roles various members of your health care teams play (e.g., primary care physicians, specialists, community health workers, asthma educators, case managers, advocates) in the delivery of asthma care.
  • Describe approaches (e.g., provider incentives and training) to ensure that asthma practice guidelines are incorporated into clinical procedures across the continuum of care.
  • Describe how patient education approaches and materials effectively translate the NIH EPR-3 Guidelines into practical and user-friendly information. Explain how you ensure that education is a component of every patient interaction, including who receives education, 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 setting), and by whom.
  • Describe approaches and procedures that ensure effective and timely communication among members of health care teams responsible for the delivery of clinical care and patient education.
  • Describe centralized systems to collect, coordinate, manage and share information on patient enrollment, diagnoses, stratification, treatments and treatment plans, referrals, utilization, and outcomes across health care teams. If you have an asthma registry, discuss who can access it and the kind of patient information it contains.
  • Integrated health care services are comprehensive and the NIH EPR-3 Guidelines are incorporated throughout the continuum of care. The program:
      »Assesses asthma severity to initiate therapy;
      » Assesses asthma control to monitor and adjust therapy;
      » Provides self-management education and encourages use of asthma action plan;
      » Integrates education into all points of care where health professionals interact with patients; and
      » Selects medication and delivery devices to meet patient's need and circumstances.
    • Example: Distinguishing Program Feature: Education, reimbusement, or incentive programs that effectively engage your providers in delivering care consistent with the NIH EPR-3 Guidelines to their patients.
    • 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 multi-disciplinary teams (e.g., primary care physicians, specialists, case managers, community partners) responsible for implementing the comprehensive asthma program.
  • Centralized methods to collect, coordinate, manage and share information on patient enrollment, diagnoses, stratification, treatments and treatment plans, referrals, utilization, and outcomes across health care teams.
  • High-performing collaborations and partnerships help to ensure delivery of integrated health care services

1.c Tailored Environmental Services (30 points)

Describe the elements of the environmental component of your asthma program, addressing both indoor and outdoor environmental triggers. Explain how you ensure that you integrate environmental management throughout the continuum of care as well as tailor environmental services to address community and patient needs.

Application GuidelinesEvaluation Criteria
  • Discuss the roles various members of your health care teams play (e.g., primary care, specialists, case managers, respiratory therapists, community health workers) in implementing the environmental management component.
  • Discuss education and counseling services to patients 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 provided to health care providers, including who receives training, the reach of the services (number or percent of providers reached), how frequently and under what circumstances or conditions (e.g., whether provider education is offered only to new providers), 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 provide to your patients to help them manage their environmental triggers.
  • Describe tools and materials distributed to your health care providers to support their clinical decisionmaking regarding environmental management of asthma (e.g., flip charts, electronic guidelines, or other diagnostic and treatment aids).
  • Describe your 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 school-, daycare-, and employer-centered environmental management services, including who receives 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 care delivery) to ensure that health care professionals receive feedback regarding patient measures taken to manage indoor and outdoor environmental triggers.
  • Elements of environmental management are addressed throughout the continuum of care.
  • Patient education and outreach programs address indoor and outdoor environmental triggers and their management.
    • Example: Distinguishing Program Feature: Effective use of incentives to ensure patient participation.
  • Multi-faceted allergen control interventions address environmental management of asthma at home and in other settings (e.g., school and work) where patients spend time. Interventions may include home visits, durable equipment, asthma counseling (including smoking cessation), or social service referrals.
    • Example: Distinguishing Program Feature: Effective community engagement that spurs others in the community (e.g., schools, employers) to take actions to reduce exposure to environmental asthma triggers in schools, child care facilities, and work places.
  • Asthma patients are identified, their sensitivity to indoor and outdoor environmental triggers is assessed, and environmental interventions are tailored accordingly.
  • Health care professionals responsible for treating asthma are trained to ensure that they are knowledgeable about environmental triggers and their management.
  • Health care professionals responsible for treating asthma receive feedback regarding patient measures taken to manage exposure to indoor and outdoor environmental triggers.
  • High-performing collaborations and partnerships help to ensure delivery of tailored environmental services.
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