National Capital Asthma Coalition Coordinating Care and Systems for Sustainability

Secured, real-time electronic data sharing network Based on collaborative intervention, data-sharing, and administrative protocols developed by frontline providers Pediatricians Clinics Emergency Depts.

Home visits Schools Daycare Community Health Workers Collaborative Care Intervention Teams

Face-to-Face and Online Care Coordination

Family Support Ctrs.

Mental Health Agencies Education, Advocacy Pharmacies Environment Specialists Bio-Surveillance System linked to Dept. of Health’s

• National Electronic Disease Surveillance System (NEDSS) • Single Point of Entry • Data Warehouse • Medicaid MIS

Children with Asthma and their Families

• Access to Quality Care • Education • Self-Management • Skills Building • Home, School & Daycare • Asthma-Friendly Environments

Schools Daycare Recreation Churches Shelters Resources Physician Asthma Care Education Training Community Education and Outreach Outreach School Nurse Open Airways for Schools IMPACT DC Coalition Meetings Health Fairs Workshops Education

Public Health Utility Systems Integration and Care Coordination

DC Primary Care Association’s Medical Homes DC

• To increase the capacity of safety net providers to ensure that District residents have access to quality primary care

NCAC’s Collaborative Teams Mobilize Care in DC’s High Asthma Morbidity Areas

7 5 9

Team 2

9 H H 7 10 10

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DC Pediatric Asthma Hospitalization 1 Rates 2 – 2000 Number of Pediatric Asthma Hospitalizations in DC 1 – 2001 Note: Rankings are similar but not identical in 2000.

Columbia Heights

8 6 5 4

Team 1

3 8 2 2 1 Source: District of Columbia Hospital Discharge Database.

Team 3

1 1 4 3

Marshall Heights Congress Heights

2 Equals hospitalizations divided by 2000 Census population data by zip code in same age category.

NCAC Teams Are Local Resource Networks

Team 1 - Marshall Heights 1. Chartered Health Plan 2. Chartered Family Health Center 3. CVS Health Connection 4. Edward C. Mazique Parent Child Center 5. East-of-the-River Family Support Collaborative 6. National Capital Asthma Coalition Comm. Health Wkr.

7. Primary Care Physicians 8. UDC-USDA Health/Environmental Services Project 9. Howard University Hospital Emergency Department 10. Children’s Hospital Emergency Department 11. Health Services for Children with Special Needs/ HSC Pediatric Center (Hospital for Sick Children) 12. Hunt Place Clinic 13. DC School Nurses 14. CVS Pharmacies

NCAC’s responsibilities:

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Facilitate and coordinate teams.

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Document collaborative care management process.

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Train physicians in PACE (NHLBI guidelines).

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Train/create certified asthma educators.

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Track care (e.g., controller prescriptions filled, changes in practice, and outcomes).

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Develop collaborative procedures (e.g., to coordinate use of written asthma action plans by M.D., child, family, pharmacist, school nurse, etc.) Team 2 - Columbia Heights 1. Mary’s Center for Maternal and Child Care 2. Chartered Health Plan 3. National Capital Asthma Coalition Comm. Health Wkr.

4. UDC-USDA Health/Environmental Services Project 5. Columbia Heights/Shaw Family Support Collaborative 6. Primary Care Physicians 7. Howard University Hospital Emergency Department 8. Children’s Hospital Community Clinic 9. Children’s Hospital Emergency Department 10. Rosemont Center (Child Care) 11. DC School Nurses 12. CVS Pharmacies Team 3 - Congress Heights 1. Chartered Health Plan 2. Primary Care Physicians 3. UDC-USDA Health/Environmental Services Project 4. Far Southeast Family Strengthening Collaborative 5. National Capital Asthma Coalition Comm. Health Worker 6. Howard University Hospital Emergency Department 7. Children’s Hospital Community Clinic: Ward 8 8. Mid Atlantic Center for Children’s Health & the Environment 9. Congress Heights Head Start 10. Unity Health Clinic: Southeast 11. Health Services for Children with Special Needs/ HSC Pediatric Center (Hospital for Sick Children) 12. Children’s Hospital Emergency Department 13. United Planning Organization 14. DC School Nurses 15. CVS Pharmacies