Washington Heights, Inwood 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
• 28 Groups asked to submit grant proposal
• 5 awards granted (Puerto Rico, Philadelphia,
  Chicago, Los Angeles, and New York)

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WIN For Asthma Team
WIN for Asthma Partners
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Leadership Task Force

• NYP/CUMC/MSP
• Mary McCord
• Dan Hyman
• Adriana Matiz
• Patricia Peretz
• Sally Findley
• Beverly Sheares
• David Evans
• Andy Nieto
• Gloria Thomas
• Melissa Pflugh
• Migdalia Onofrieti

• Partners
• Yvonne Stennett (CLOTH)
• Evelyn Perdomo (AD)
• Anita Grossbard (FGCEC)
• Maria Lizardo (NMIC)
• Carol Odnaha (VNSNY)
• Lori Bukiewicz (AFSZ)
• Fajah Ferrer (NMPP)

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Primary Objectives

• Establish a community-wide network of care
• Improve severe asthma outcomes
• ED visits
• Hospitalizations
• School absences
• Help children with asthma to live healthy, active
  lives!

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Path to get there

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

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Who are We?
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Identifying Children with Asthma and High Risk
Asthma

• Referral sources
• ED and CHONY (411 children)
• 5 Elementary schools participating in HSHF
  2234/4166 children surveyed, 95 high risk)
• Day Care programs (31 sites, 2179 children, 8
  high risk)
• Referrals from pediatric primary care providers
  (13 children, 6 from ACN)

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Care Coordination Services

• CC Services provided by CBO-based Family Asthma
  Workers (FAWs)
• Daily hospital rounds recruitment
• Asthma 101 Education
• Environmental home assessment Integrated Pest
  Management interventions
• Goal setting support/ follow up
• Support linkage and communication to medical home
• Referrals for other services

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Care Coordination (to date)

• High Risk Engagement

• CC Services

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Preliminary Outcomes
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Provider Outreach

• Engage providers in Quality Improvement work for
  delivery of asthma care
• PDSA Methodology
• Engagement all clinical staff members
• Offer providers asthma management tools and chart
  reviews
• Train providers in Physician Asthma Care
  Education (PACE)
• Emphasis on effective communication strategies
  health literacy
• Target classification/ NHBLI guidelines
• Create linkages families, providers, resources/
  information
• Offer providers Care Coordination services for
  patients

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Provider Outreach

• Progress to date
• 5 PACE trainings
• 98 participants trained
• Individual Provider Outreach
• 33 providers engaged
• 33 completed assessment
• 15 completed one PDSA Quality Improvement cycle
• 8 completed two PDSA Quality Improvement cycles
• 24 have had 3 or more visits (including needs
  assessment)

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Looking Forward

• Provider Outreach
• Outreach to providers with patients in Care
  Coordination
• PACE training for new GPGP, Pulmonary Division
  faculty and community practitioners
• Outreach
• Environmental Advocacy and school based efforts
• Integration of parent of child with asthma into
  MSCHONY Family Advisory Council
• Care Coordination
• Strengthen sustainability of program within
  hospital operations
• Strengthen integration of CC services into CBO
  structures

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Program Contacts

• Program Manager- Patricia Peretz
• pap9046_at_nyp.org
• 212 305 4065
• Medical Director Adriana Matiz
• lam2048_at_columbia.edu
• 212 342 1917

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