I.  Initiative (CAI) Objectives

The primary goals of the Childhood Asthma Initiative are to reduce asthma severity, prevent emergency room and in-patient hospital use to the extent possible, and to improve the lives of homeless and poor children in New York City. Much of this work has focused on the South Bronx, where asthma is a leading cause of hospitalization among children. Children’s Health Fund (CHF) surveillance activities have found that up to 40% of children in New York City shelters have symptoms consistent with asthma. In order to address the asthma epidemic and other health care problems among homeless families and South Bronx residents, the Children’s Health Fund’s New York Programs integrate best-practice asthma care into a comprehensive primary care model. This care is consistent with the National Heart Lung and Blood Institute (NHLBI) Guidelines for the Diagnosis and Management of Asthma.

The CAI represents a multi-disciplinary approach to asthma care, directly impacting the lives of asthma sufferers, as well as parents and community members. CAI objectives are to:

·         provide CAI high-quality clinical services, including clinical education tools and psychosocial services in order to reduce morbidity among medically underserved children and family members in New York City;

·         create an asthma-friendly community in the South Bronx through creative and adaptable forms of community education; and

·         promote replication of the CAI by disseminating findings and information about the model among pediatric and community health professionals.

The Childhood Asthma Initiative: A Unique Form of Asthma Care

The CAI model is a unique, effective and highly replicable form of asthma care. Currently in operation at CHF’s South Bronx Health Center for Children and Families and the New York Children's Health Project (which delivers primary care to homeless families via mobile medical units and shelter-based clinics) the key components of the CAI are described below. Developing a Business Plan

• CAI clinical care is fully integrated into the busy primary care setting. This greatly increases access to guidelines-based asthma care for underserved populations.
• Clinical care is interdisciplinary in that it incorporates clinical education and psychosocial services for parents.
• Asthma community education is offered toward the goal of creating an “asthma friendly community” in the South Bronx. The CAI includes creative group curricula appropriate for use in a number of settings.
• CAI is one of the first programs to create parent educational materials that teach families about the NHLBI asthma guidelines.
• CAI outcome data have proven the program to be effective over time. Establishing the success of the initiative through evidence is key to gaining acceptance and replicating the program.

CAI Clinical Services

To address the high rate of asthma among homeless and poor children in New York City and the South Bronx, the CAI has adapted and effectively incorporated the NHLBI best practice guidelines-based asthma clinical care into primary care visits at The Children’s Health Fund’s New York Programs. CAI clinical care is possible through the use of a CAI Assessment Tool, which is used by medical providers to inform clinical decisions. Allergy skin testing is also available, because inner-city children with asthma have shown increased sensitivity to indoor allergens that exacerbate their asthma severity. Given the important role of parents in managing their children's asthma, CAI incorporates asthma education during medical visits. When appropriate, medical providers refer parents for psychosocial services. This highly replicable program component enables busy pediatric offices to provide guidelines-based asthma care. Each year, the CAI provides care to more than 1,000 homeless and poor children who have asthma. Key elements of CAI clinical and clinical education services are summarized below.

·         Clinical Visits facilitate medical management of asthma through the use of clinical tools as well as asthma education tools developed by the CAI team. This clinical care is provided in the general primary care setting. In addition, medications are available free of charge to patients who do not have access due to lack of (or insufficient) health insurance.

·         CAI Assessment Tool is the adaptation of the NHLBI guidelines into a streamlined clinical assessment tool that is used by medical providers during asthma visits to inform clinical decisions regarding appropriate medical treatment.

·         Clinical Asthma Education is offered by medical providers during the course of clinical visits to teach parents how to medically manage their children's asthma. CAI asthma education tools include the Photo Asthma Action Plan and the Stay Ahead of Asthma Guide. Providers are able to use these visual tools to guide parents through complex information. CAI developed the Stay Ahead of Asthma Guide as an easy-to-read book written in English and Spanish to introduce the NHLBI guidelines to parents. Photo Asthma Action Plan utilizes photographs of common medications and provides parents with information about how and when medications should be used, as well as what to do in an emergency.

·         Allergy Skin Testing, when brought into primary care, offers medical providers another resource for treating asthma, given the close relationship between allergies and asthma. Equipped with test results, medical providers can treat children’s allergies, which frequently improves asthma symptoms. Test results enable medical providers to identify the offending allergens, and to recommend harm reduction strategies. Frequently, parents were not aware of the things that trigger their children's asthma prior to the allergy testing. Allergy testing usually requires a visit to a specialist.

·         Psychosocial Services are integral to the appropriate management of asthma patients in underserved communities. CHF has found that a high percentage (72%) of CAI parents present symptoms consistent with depression. The implications of untreated parental mental health needs (including possible compromised care) are very serious for families with children suffering from asthma. The CAI offers psychosocial service referrals to all asthma parents. Social workers conduct assessment and develop treatment plans that may include one-on-one counseling, case management, and referral for psychiatric assessment. In addition, CAI Psychosocial Groups are available at shelter sites for homeless families.

Creating an “Asthma Friendly Community” through Community Education

Particularly in neighborhoods such as the South Bronx that are hard-hit by asthma, it is essential to develop an asthma-friendly community. The CAI has made substantial progress towards creating an asthma-friendly community by reaching nearly 2,000 people through asthma education and outreach to schools, community organizations, and public housing facilities. Checklist for Organizing The CAI team has developed a number of curricula that are highly replicable and suitable for a variety of audiences, venues and time restrictions. An important component of these community activities is educating families about the importance of having a primary care provider, how and when to access health care, and the availability of primary care and asthma care at the South Bronx Health Center for Children and Families. Key elements of CAI Community Education are summarized below.

·         Asthma Curriculum for Public Schools is a two-week expansion to the literacy curriculum that has been used at several schools in the South Bronx. The curriculum allows students to conduct group research on the characteristics, triggers, medication and management of asthma. Students use self-expression, research and collaborative learning to present their findings at a culminating "publishing party."

·         Asthma Create, Read, Educate, Write (C.R.E.W.) is a two-session curriculum developed by CAI to teach school-age children about asthma and asthma management in a fun, interactive and hands-on learning environment.

·         CREW Harmonica Workshops team-up CAI staff with musicians to teach children about asthma and how harmonica playing can help strengthen their lungs. The two-session curriculum includes an asthma lesson and an interactive session when students “jam” with the musicians.

·         One-Hour Asthma Sessions are provided to teach school-aged children in the South Bronx about asthma when time constraints do not allow for a full Asthma C.R.E.W. workshop.

·         Asthma Forums are group education workshops designed to educate homeless and housed parents about asthma. The curriculum developed by the CAI team includes asthma symptoms, triggers, medications, and the importance of having a medical home.

·         Asthma Training Sessions educate shelter staff and other service providers at community-based organizations where there are significant numbers of children with asthma.

·         Clinical Outreach to Public Housing in the South Bronx are outreach activities that are designed to educate families about asthma while linking them with the health center.

Dissemination and Replication

The CAI model and findings are widely disseminated in order to promote greater awareness and replication of the model. The target for CAI dissemination work includes policy makers, health administrators, clinicians, public health advocates, and community health centers, which are reached through a combination of presentations at regional and national conferences and academic meetings, journal articles, web sites and/or general audience media. Dissemination activities focus on the success of the CAI model in treating asthma in underserved communities, the role of allergy testing in managing asthma, and the need for psychosocial services. Upon finalization, CHF will also disseminate a cost-benefit analysis of the CAI model.

CAI Professional Dissemination and Replication activities include:

·         Population-based Surveillance has been conducted to determine the population prevalence of asthma among homeless children in New York City shelters. The CAI has documented a 40% asthma prevalence rate for homeless children (see the attached Archives of Pediatrics and Adolescent Medicine). This exceeds the national pediatric asthma rate by a factor of six, and is the highest asthma prevalence rate established for any population.