Washington HeightsInwood Network for Asthma

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• Washington Heights-Inwood Network for Asthma

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Background

• Summer 2005 Merck Company Foundation announces
  Merck Childhood Asthma Network 2 million over
  4 yrs grant
• Work group collaborated in submission of letter
  of intent (166)
• 28 Groups asked to submit grant proposal
• 5 awards granted (Puerto Rico, Philadelphia,
  Chicago, Los Angeles, and New York)

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What is our mission?

• WIN for Asthma will strengthen community-wide
  asthma management for the thousands of children
  afflicted with asthma in Northern Manhattan by
  creating a network of care.

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Who is WIN for Asthma?

• NewYork Presbyterian, CHONY
• CUMC Dept of Pediatrics/ Mailman SPH
• Asthma Basics for Children (ABC)
• Healthy Schools Healthy Families
• Community Premier Plus
• Alianza Dominicana, CLOTH, NMIC, Fort George
  Community Enrichment Center
• Visiting Nurse Services of New York
• NICHQ
• Community Physicians of NYP Hospital at CUMC
• NYC Dept of Education
• DOHMH

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WIN for Asthma
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WIN for Asthma Staff
WIN for Asthma Partners
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Leadership Task Force

• NYP/CUMC/MSPH
• Mary McCord
• Dan Hyman
• Adriana Matiz
• Sally Findley
• Beverly Sheares
• David Evans
• Matilde Irigoyen
• Representative from CP of NYP
• Cheryl Ragonesi
• Gloria Thomas
• Program Coordinator

• Partners
• Yvonne Stennett (CLOTH)
• Miriam Mejia (AD)
• Leonore Peay (FGCEC)
• Maria Lizardo (NMIC)
• Carol Odnaha (VNS)
• Sandra Comerie-Smith (CPP)
• Patti Simino Boyce (NICHQ)

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Who is the community we will serve?

• Washington-Heights and Inwood with expansion to
  West Harlem in the last 2 yrs of the grant
• Inner-city, diverse, immigrant
• 41 live below the poverty level (under the age
  of 18)
• Major environmental pollutants
• Prevalence of asthma estimated at 30 based on
  ABC survey

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What are our goals?

• To reduce severe asthma exacerbations and their
  sequelae
• ED visits
• Hospitalizations
• School absences

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How will we get there?

• Enhance identification of children with asthma
  and provide care coordination of high risk
  children
• Provide PACE (Physician Asthma Care Education)
  training and post-training support for providers
• Expand asthma education programs for children and
  parents
• Facilitate asthma-safe environments

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How will we identify and help children with
asthma?

• Work with selected elementary schools and day
  cares through existing partnerships
• HSHF
• ABC
• NYC Dept of Education
• NYC DOHMH
• CLOTH, Alianza Dominicana, Fort George Community
  Enrichment Center, and NMIC
• Collaborate with NYP hospital and community
  practices
• Ambulatory Care Network, CHONY
• Community Physicians of NYP
• Health care providers enrolled with CPP
• Community Premier Plus referrals of high risk
  patients

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What will be our approach to children with asthma?

• Through collaborative efforts across all our
  partnerships we will
• Identify children with asthma
• Assess children using stratification scheme for
  risk factors
• Refer children to WIN for Asthma
• Provide follow up through care coordination
  services

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Stratification of Risk Factors
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Linkage and Coordination
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What services will we provide for those children
with asthma?

• Asthma education sessions at schools, day care
  centers or CBOs
• Link to asthma trained health care provider
• Followed by school or day care center team
• Refer to Open Airways through school nurse
• Family Asthma Worker
• VNS referral

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What do Family Asthma Workers do?

• Receive training by ABC staff
• Work with families
• Provide individualized asthma education
• Home visits
• Environmental control ( training in Integrated
  Pest Management and Inner City Asthma Study)
• Accompany families to health care provider visits
• Daily hospital rounds on CHONY inpatients
• Work with Network
• Regular feedback and progress from families to
  WIN for Asthma

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What will Visiting Nurse Services of NY do?

• Supplementary training by ABC staff in
  environmental control measures by WIN for Asthma
• Referrals only for high risk patients by network
• Coordinate communication between providers and VNS

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What will we do initially for health care
providers?

• Modified PACE training
• Flexible hours
• Invite not only physicians from practices
• Emphasize effective communication strategies
• Target classification /NHBLI guidelines

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How will we follow up with our providers?

• NICHQ will mentor Provider Liaison in PDSA
  methodology
• Work with providers and practices on creating
  small tests of change in the delivery of care
• Follow up and promote system changes
• Assist with chart reviews, development of tools

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How will WIN work in our schools?

• HSHF (PS 128, PS 132, PS 152, PS 4, PS 180)
• Coordinate with DOHMH Nurse for Open Airways
• Assess for insurance coverage, immunizations, and
  physical exam
• Encourage medication administration form is on
  file at nurses office
• Refer all high risk children to WIN
• ABC
• Administer and collect survey to identify
  children with asthma
• Asthma Mentor working in collaboration with
  school staff and parents
• Coordinate asthma educational workshops at school

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Day Care Center Teams - ABC

• Survey to identify children with asthma
• Train day care staff on asthma education and
  management
• Provide parent education
• Asthma mentor working with day care center staff
  and parents
• Referrals of high risk children to WIN

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How does Community Premier Plus support WIN for
Asthma?

• Coordinate with case managers at CPP on
  management and referral of high risk patients
• Case identification via hospital ED and admission
  data
• Medication filling
• Feedback tools for providers
• Group asthma education sessions
• Refer providers for PACE training

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What is the role of the Tobacco Cessation Clinics
NYP?

• Referrals made via network for all identified
  cases with exposure to tobacco
• Develop outreach through all partners at WIN for
  Asthma

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Contacts

• Program Manager- Kelly Lubeck
• kel9022_at_nyp.org
• 212 305 4065
• Medical Director Adriana Matiz
• lam2048_at_columbia.edu
• 212 342 1917