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Table 2. List of potential health system changes and associated resources

Asthma Health Disparities Collaborative Coalition Guide

Health system changeResources/support
NationalState/coalition
Health care organization: Create a culture, organization and mechanisms that promote safe, high quality care.
Assist senior leadership in determining the value of improving chronic care

Business Case Studies:
http://www.improvingchroniccare.org

Preparing for an Executive review of Improvement Projects:
http://www.ihi.org/IHI/Topics/LeadingSystemImprovement/Leadership/Tools/ExecutiveReviewofProjectsIHI+Tool.htm

 
Make improving chronic care part of the health center's vision, mission, goals, and performance improvement and business plans.

Leaders' Guide—Developing the Business Case for Planned Care:
http://www.healthdisparities.net/hdc/hdcsearch/isysquery/ 0079f1ee-2ec2-441a-9652-f4a4b1cd1722/3/doc/

Changing Practice, Changing Lives: The Health Disparities Collaboratives, Training and Promotional Videos:
http://www.healthdisparities.net

 
Orient new clinicians to the collaborative

Asthma Health Disparities Collaborative Training Manual for Chronic Conditions:
http://www.ihi.org/IHI/Topics/ChronicConditions/AllConditions/Tools/ HealthDisparitiesCollaborativesTrainingManualforChronicConditions.htm

Texas Association of Community Health Centers Distance Learning Tool with training modules for the Collaborative. These courses may be used by individuals to become oriented to the Care Model, learn how to apply the model to any of the targeted chronic illnesses, or simply as a Collaborative training tool and resource. To access, go to http://classroom.tachc.org and select "Request an Account."

 
Embed measurement and monitoring in work flow.

Senior Leader Monthly Report Form:
http://www.healthdisparities.net/hdc/hdcsearch/isysquery/78429fb9-4b8c-4543-92af-eaeb35602044/14/doc/

Example of Senior Leader Report:
http://www.healthdisparities.net/hdc/hdcsearch/isysquery/ec4f2412-bf58-461e-ac04-4c207cfe21f8/21/doc/

 
Assess organizational and individual understanding of culturally and linguistically effective care.

Indicators of Cultural Competence in Health Care Delivery Organizations: An Organizational Cultural Competence Assessment Profile: http://www.hrsa.gov/culturalcompetence/indicators/default.htm#conclusion

Andrulis D. Cultural Competence Self-Assessment Protocol for Community Health Centers:
http://healthdisparities.net/hdc/hdcsearch/isysquery/ dff4e565-a108-4b4c-a826-6e84c418bfb6/5/doc/

 
Financial or organizational incentives to participate in quality improvementPay for Performance Incentive Programs in Healthcare 2003:
http://www.leapfroggroup.org/media/file/Leapfrog-Pay_for_Performance_Briefing.pdf
 
Self-management support: Empower and prepare patients to manage their health and health care.
Consumer/patient asthma education

National Asthma Education and Prevention Program:
http://www.nhlbi.nih.gov/about/naepp

Medline Plus Asthma Tutorial:
http://www.nlm.nih.gov/medlineplus/tutorials/asthma/htm/index.htm

National Institute of Allergy and Infectious Diseases, How to create a dust free bedroom:
http://www.niaid.nih.gov/factsheets/dustfree.htm

Starlight, Starbright Children's Foundation, Quest for the Code®:
http://www.starlight.org/site/c.fuLQK6MMIpG/b.2667067/ k.4368/Quest_for_the_Code_Now_Online.htm
(online asthma game that helps children and teens learn how to manage their asthma, find coping tips and get advice.)

Environmental Protection Agency:
http://www.epa.gov/ebtpages/humahealtheffectsasthma.html

Michigan Asthma Resource Kit, Patient Section:
http://www.getasthmahelp.org/mark%20patient%20files.asp

Emphasize and educate the patient and family about their role in the management of asthma:

  • Simple messages from primary care provider.
  • Consistent approach.
  • Culturally and linguistically appropriate.

American Lung Association Open Airways for Schools,
http://www.lungusa.org/site/pp.asp?c=dvLUK9O0E&b=44142#volunteers

The Group Health Center for Health Studies (CHS) Readability Toolkit (2006) helps to create materials that patients and health care consumers can understand: http://www.improvingchroniccare.org/downloads/readabilitytoolkit_seconded_092606.pdf

Health Disparities Collaboratives Web site has several sources on health literacy and limited literacy: http://www.healthdisparities.net/hdc/hdcsearch/isysconcept/ Special Populations—Considerations/Health Literacy—Limited Literacy/

Office of Minority Health Web site has culturally appropriate patient education materials:
http://www.omhrc.gov

 
Use effective self-management support strategies that include assessment, goal setting, action planning, problem solving, and followup.

Assessment:

  • American Lung Association Asthma Control Test (also available in Spanish):
    http://www.asthmacontrol.com/
  • Holyoke Health Center Northeast Cluster. Asthma and Environmental Self-Assessment:
    http://www.healthdisparities.net/hdc/hdcsearch/isysquery/ c98d1c1f-5ac8-4db7-91f5-febe10a4c65d/1/doc/

Goal Setting:

  • Importance Ruler and Confidence Ruler*
  • Self-management support tool,
    http://improvingchroniccare.org/downloads/healthy_changes_plan.doc

Shared Care Plan:
http://www.ihi.org/NR/rdonlyres/D100E7F6-2314-4533-8D0B-B7AB926DA47D/353/Tool_SharedCarePlan1.doc

Asthma Peak Flow Diary:
http://www.pedipress.com/dap_apfd_eng.html

Supporting Self Management With the 5 A's:
http://www.ihi.org/IHI/Topics/PatientCenteredCare/ SelfManagementSupport/EmergingContent/ SupportingSelfMgmt5AsClinicianPatientInteractions.htm

Goal Setting:

  • Asthma Action Plans: http://www.getasthmahelp.org/actionplan_components.asp

Asthma Peak Flow:

  • Peak Flow Tracking Sheet: http://www.getasthmahelp.org/MARK Patient/Peak Flow Tracking chart.pdf
  • Peak Flow Diary with Instructions: http://www.getasthmahelp.org/MARK Patient/Peak flow diary w_directions.pdf
Delivery system design: Assure the delivery of effective, efficient clinical care and self-management support.
Use the registry data to review care and plan visits [see clinical information system]Whitney M Young Jr. Health Center, Albany, NY. Integrating Your Asthma Registry in Daily Care:
http://www.healthdisparities.net/hdc/hdcsearch/isysquery/ 5be2039a-d447-4cd5-8bcc-7c89557dceac/1/doc/
 
Define roles and distribute tasks among team members to optimize staff efficiency and promote a multi-disciplinary care system.

Huddle List:
http://www.healthdisparities.net/hdc/hdcsearch/isysquery/ 09257609-3615-4caa-af13-1d0b957e00ed/1/doc/

Staff Suggestions for Huddle Contributions:
http://www.healthdisparities.net/hdc/hdcsearch/isysquery/ 09257609-3615-4caa-af13-1d0b957e00ed/2/doc/

 

Use planned visits to support evidence-based care:

  • Visit initiated by health center.
  • Typically 20-40 minutes long.
  • Reviews care priorities.
  • Occurs at regular intervals as determined by patient and provider.
  • Team members have clear roles and tasks.
  • Delivery of clinical management and patient support are the key aspects of care.

Asthma Visit Flow Sheet (condensed):
http://www.midwestclinicians.org/files/health/tools/ds_asthmaflow.pdf

Asthma Clinical Visit Flow Sheet:
http://www.midwestclinicians.org/files/health/tools/ds_asthmaclinicalflow.pdf

Group Visit Starter Kit:
http://www.healthdisparities.net/hdc/hdcsearch/isysquery/ f8beb25b-9a2b-49d8-b5c1-3babc4682f0a/11/doc/

Planning Group Visits for High Risk Patients, American Academy of Family Physicians:
http://www.aafp.org/fpm/20000600/33plan.html

 

Make designated staff responsible for and ensure regular followup

  • Wide variety of methods [in-person, email, phone], whichever the patient prefers.
  • Make sure followup occurs; missed followup destroys trust.
  • Use outreach and community opportunities.
 Asthma coalitions link to volunteers and others who can assist with followup.
Provide or link to clinical case management services. Coalitions provide or locate asthma clinical case management services in community
Provide or link to lay-educator led education. 

MI Partners on the PATH (Chronic Disease Self-Management Program)
http://www.mipath.org

Support Groups: http://www.aafa.org/esg_results.cfm?state=MI

Create a system to identify and vaccinate all patients with asthma for influenza. FQHCs use Michigan Childhood Immunization Registry to track influenza immunization for children with asthma.
Linkage to emergency department for followup from ED visits. FLARE: Emergency Department Discharge Asthma Instructions:
http://www.getasthmahelp.org/FLARE.asp
Provide care that patients understand and that fits their culture.

Indicators of Cultural Competence in Health Care Delivery Organizations: An Organizational Cultural Competence Assessment Profile: http://www.hrsa.gov/culturalcompetence/indicators/default.htm#conclusion

Andrulis D. Cultural Competence Self-Assessment Protocol for Community Health Centers:
http://healthdisparities.net/hdc/hdcsearch/isysquery/ dff4e565-a108-4b4c-a826-6e84c418bfb6/5/doc

 
Decision support: Promote clinical care that is consistent with scientific evidence and patient preferences.
Embed evidence-based guidelines into daily clinical practice.

National Asthma Education and Prevention Program Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma:
http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm

National Guideline Clearinghouse™:
http://www.guideline.gov

Shenandoah Valley Medical System, Inc. Asthma Progress Note:
http://www.healthdisparities.net/hdc/hdcsearch/isysquery/ 2d28c0b5-3566-48eb-bcf5-ae4f8afa983e/1/doc/

Michigan Asthma Resource Kit, Professional Section:
http://www.getasthmahelp.org/mark pro files.asp

Michigan Quality Improvement Consortium Asthma Guidelines for Primary Care:
http://www.mqic.com/guid.htm

Referral to specialist to integrate specialist expertise and primary care.

  • Practice agreements.
  • Real-time consultation.
  • Email exchanges.
  
Provide skill oriented interactive training programs for all staff.

Provider Training in Choices and Change:
http://www.bayerinstitute.com

One Minute Asthma Training:
http://www.pedipress.com/omat_main.html

Texas Association of Community Health Centers Distance Learning Tool with training modules for the Collaborative. To access, go to:
http://classroom.tachc.org (Select "Request an Account.")

Coalition provides, obtain resources, or otherwise assists with provider education

Share guidelines and information with patients:

  • Wallet card.
  • Decisionmaking tools.
One Minute Asthma, 7th Edition:
http://pedipress.com/book_oma.html
 
Develop refill protocol to identify overuse of beta antagonists.  
Clinical Information systems: Organize patient and population data to facilitate efficient and effective care.
Patient registry to identify population and to facilitate individual patient care planning. Midwest Clinician Network, Patient Electronic Care System (PECS) registry:
http://www.midwestclinicians.org/health/reg_report.htm [based at the Michigan Primary Care Association]
Develop processes for use of the registry, including designating personnel or volunteers to enter, assure data integrity, and maintain the registry.

Using Monthly Health Center Data:
http://www.healthdisparities.net/hdc/hdcsearch/isysquery/ f2b271a1-4430-4866-849f-62287e8103b9/12/doc/

Senior Leader Monthly Report Form:
http://www.healthdisparities.net/hdc/hdcsearch/isysquery/ 78429fb9-4b8c-4543-92af-eaeb35602044/14/doc/

 
Use the registry to generate reminders and care planning tools for patients and providers Midwest Clinician Network, Patient Electronic Care System (PECS) registry:
http://www.midwestclinicians.org/health/reg_report.htm
[based at the Michigan Primary Care Association]
Conduct monthly identification of poorly controlled asthma via billing data; identify relevant subpopulations for proactive care. Midwest Clinician Network, Patient Electronic Care System (PECS) registry:
http://www.midwestclinicians.org/health/reg_report.htm
[based at the Michigan Primary Care Association]
Facilitate individual patient care planning.Huddle List:
http://www.healthdisparities.net/hdc/hdcsearch/isysquery/ 09257609-3615-4caa-af13-1d0b957e00ed/1/doc/
 
Data analysis to monitor performance of practice team and care systemUsing Monthly Health Center Data:
http://www.healthdisparities.net/hdc/hdcsearch/isysquery/ f2b271a1-4430-4866-849f-62287e8103b9/12/doc/
Midwest Clinician Network, Patient Electronic Care System (PECS) registry:
http://www.midwestclinicians.org/health/reg_report.htm
[based at the Michigan Primary Care Association]
Community resources and policies: Mobilize community resources to meet patient needs.

Link to community, evidence-based resources:

  • Referral system.
  • Incentives for patient participation.
  • Promotion and marketing of community services.
Freedom from Smoking online:
http://www.ffsonline.org/

Power Breathing, Wee Wheezers & Wee Wheezers At Home, and other programs and services offered by the Asthma & Allergy Foundation of America, Michigan Chapter:
http://www.aafamich.org/services.html

Michigan Tobacco Quit Line:
1-800-480-QUIT (1-800-480-7848)

AIM Community Web site, including links to asthma coalitions:
http://www.getasthmahelp.org

American Lung Association of Michigan:
http://www.alam.org/

Asthma coalitions to provide referral and community information, as requested by the FQHC.

Form partnerships with community organizations to support and develop programs that meet gaps. "Never Judge a Book by Its Cover, and Other Important Lessons About Asthma" school packets:
http://www.getasthmahelp.org/intro_schools.asp
Form partnerships with community organizations to obtain donations/resources for educational materials, provider education, medications, equipment, and other necessary supplies/materials.Pharmaceutical companies
Community foundations
Prescription assistance programs
Asthma coalition to provide links to possible pharmaceutical, foundation, and community partners to assist with providing educational materials, equipment, and other supplies.
Advocate for policies to improve care. Involve FQHC in MAAC and its subcommittees.

Note: National and State/coalition resources are listed in all areas in which they are appropriate.
* Examples of importance and confidence rulers are presented in Appendix D.

Return to Document

Page last reviewed September 2007
Internet Citation: Table 2. List of potential health system changes and associated resources: Asthma Health Disparities Collaborative Coalition Guide. September 2007. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/nhqrdr/asthma-health-disparities/table2.html