Alliance staff contact: Ed Stomski | 518.701.2283
Objective: Ensure implementation of asthma self-management skills including home environmental trigger reduction, self-monitoring, medication use and medical follow-up to reduce avoidable emergency department and hospital care. A special focus will be on children for whom asthma is a major driver of avoidable hospital use.
Project Description: Despite best efforts of practitioners to implement evidence-based practices, asthma patients continue to have difficulty controlling their symptoms. The goal of this project is to develop home-based services to address asthma exacerbation factors. Special focus will be on children for whom asthma is a major driver of avoidable hospital use.
Definition of Engaged Patients: The number of participating patients based on home assessment log, patient registry, or other IT platform.
- Expand asthma home-based self- management program to include home environmental trigger reduction, self- monitoring, medication use, and medical follow-up.
- Establish procedures to provide, coordinate, or link the client to resources for evidence based trigger reduction interventions.
- Specifically, change the patient’s indoor environment to reduce exposure to asthma triggers such as pests, mold, and second hand smoke.
- Develop and implement evidence based asthma management guidelines.
- Implement training and asthma self- management education services, including basic facts about asthma, proper medication use, identification and avoidance of environmental exposures that worsen asthma, self-monitoring of asthma symptoms and asthma control, and using written asthma action plans.
- Ensure coordinated care for asthma patients includes social services and support.
- Implement periodic follow-up services, particularly after an emergency department or hospital visit occurs, to provide patients with root cause analysis of what happened and how to avoid future events.
- Ensure communication, coordination, and continuity of care with Medicaid Managed Care plans, Health Home care managers, primary care providers, and specialty providers.
- Use electronic health records (EHRs) or other technical platforms to track all patients engaged in this project.