Coalitions: Integrating Community-Based Asthma

Control Strategies

Jim Krieger, MD, MPH

Robert Groves, MA, MPH

Marielena Lara, MD, MPH

Kimberly Wicklund, MPH

November 2003

Concepts of Integration

• Service coordination– Providing asthma services coherently and

consistently– Linking providers to assure delivery of full range

of services

• Cross-institutional Collaboration– Developing a shared vision– Sharing resources– Joining in program implementation and

advocacy

• Multi-disciplinary Collaboration

Families Want Integration

“Nurses, doctors, and parents need to connect. We all want to be involved and we want to know what’s going on with our kids.”

Primary Care Providers Want Integration

• Don’t know when kids admitted to ED or hospital

• Don’t know if medications are refilled

• Aren’t connected to schools and childcare

Barriers to Integration• Structural

– Silos– Staff not available to participate in integration work– Leadership not available to provide direction

• Cultural– Doing it your way– Turf and control

• Logistical– Working out the details– Communicating and coordinating are time-consuming

• Pressures to generate revenues, meet performance

targets

Paradox of Integration

While an integrated system will ultimately be more efficient and

effective, getting there takes time and may appear inefficient

Overcoming Barriers:Coalitions Bring Together Sectors

• Safe, neutral space • Forum to network and learn• Common vision• Leadership • Coordination of resources• Build relationships

Coalition MembershipPlease circle the category (organization) that applies to you

CSAS

N=294

Health Care Provider 38%(32-45%)

Community 22%(8-48%)

School 11%(2-21%)

Other 13%(6-21%)

HMO 7%(3-12%)

Health Department 15%(3-34%)

Coalition MembershipGroups not well represented

Category All Range

Health depts. 9.9% 4-24%

Community org. 44.2% 18-55%

Providers 15.0% 4-24%

Schools 5.8% 0-18%

HMO 8.5% 0-28%

Residents 31.3% 12-45%

CSAS

N=294

Other includes media, business, faith-based, housing, elected officials and staff

Coalition Membership

Does the coalition have sufficient representation to accomplish objectives?– Yes: 70%– Range: 33-90%

CSAS

N=294

Overcoming Barriers:Steering Committees

• Primary mechanism for integration• Decision-making body of coalition• Gathering of organizational decision-

makers• Champion for integration• Strategic planning• Collaborative approach to grant-writing

and new program development

Overcoming Barriers:Steering Committees

• Managed Care Organizations

• Medicaid Program• Hospitals• Emergency Departments• Clinics• Physicians• Community Health

Workers• Nurses• Universities

• ALA• AAFA• CBOs• Community Asthma

Programs• Community Residents• Faith-based Organizations• School Districts• Coalition Staff• Public Health• DHHS

Integrating Care For Individuals

• Community Health Workers– Link families with schools, childcare,

health providers, public housing– Advocate for families for

accessibility and consistency of services

• Care Coordinators– Facilitate access to services– Coordinate services across service

providers– Back-up CHWs

• Individual Asthma Action Plans

Philadelphia Link Line

1Emergency Department Children's’ Hospitals

Elementary Schools Philadelphia School Dist.

Community Based Sites

Care Coordination/Case Management Fight Asthma Milwaukee

• ED or clinic notifies care coordinator at local health department

• Coordinator arranges linkage to appropriate services– Home visits by nurse case manager:

– Home visits by health department environmental inspector

– Calls to encourage follow-up with medical home

– Refer to parent mentor program

– Refer to family asthma education

– Info about childcare/school asthma education

• Shared evaluation and educational protocols

Care CoordinationAlianza, Puerto Rico

Nurse clinical coordinator

• respected and accepted by community

• works with community health care workers to coordinate care

• links patients with MCO, local and state health departments, and other agencies of the coalition.

Cross-Project Integration GroupKing County Asthma Forum

• Single asthma referral phone number• Staffed by community health workers• Refer to coalition member services– home visits (Allies, Healthy Homes, MHE)– public health nurses– primary care– family education groups

• Triage protocols• Joint outreach and recruitment

Integration Across Organizations

• Community Asthma Action Plan– Summary of shared vision– Developed in a participatory, collaborative process– Defines roles

• Develop multiple forums to foster integration– Coalitions as the overarching roof– Cross-project coordination groups– Learning collaboratives for clinics– Joint proposals and projects– Conferences and community meetings

Integration Across Organizations

• Asthma team• Common tools, guidelines

and messaging– Single asthma action plan– Shared educational

resources and programs– Consistent asthma control

protocols and guidelines– Consistent key asthma

messages

Integration Across Organizations

Linking Providers and CHWs

• King County– Learning Collaborative – Quality Improvement (Improvement Model)– Registry prompts– Systematized referral and communication

• Long Beach– Provider education (PACE)– Fax referrals to CHWs

Integration Across Organizations

Coordination of Asthma Policy/Advocacy

• Long Beach– Better Housing: Providers and Landlords– Cleaner Air: Parents, Residents, Legislators,

Schools, Environmental Groups

• King County– Public Housing– Medicaid reimbursement

Future Directions

• Integrating beyond asthma– Tobacco control– Other chronic conditions: STEPS

• Policy and advocacy• Bringing to scale• Sustaining integration

To conclude:

• Integration doesn’t come easily but there are effective strategies to help get there.

• Paths to integration will vary by community and must fit the local landscape.