Appendix

Building or expanding asthma management in a health system

Health systems have an opportunity to utilize and invest existing resources and clinical expertise to promote value-based care by offering asthma self-management education in a clinic or home setting, home environmental assessment, and/or durables needed to mitigate environmental triggers.

Consider piloting an asthma education program. A pilot can help identify the most effective approach given the constraints and resources available to your health system. While minimizing the initial costs, a successful pilot program can demonstrate cost-effectiveness and justify larger-scale investment.

Identify current or a new position to dedicate percentage of time to conduct asthma self-management education and home environmental assessment in clinic or home setting.

• Setting: Conduct one-on-one asthma self-management education with patient and/or caregiver in clinical and/or home setting.
• Eligibility: Depending on staff capacity, patient load, and allocation of time, eligibility can focus on those newly diagnosed with asthma and/or those with poorly controlled asthma (i.e., asthma-related hospitalization or emergency department visits, frequent urgent care visits, overuse of oral steroids, and/or overuse of rescue inhalers).
• Staffing: Registered nurse, respiratory therapist, clinical social worker, asthma educator, health promotion specialist, or community health worker.
  • For current position(s), update job description and provide training as needed.
  • For new position(s), include as part of job description and hiring process and provide training as needed.
• Visits: Complete two visits covering AS-ME and home environmental assessment.
  • Visit 1: Approximately 60–90 minutes
    • Complete as asthma control assessment at baseline with the client (parent/guardian if under 18).
    • Provide self-management education. Cover as many sections and corresponding teach-backs as time allows. The sequence and depth of each topic will depend on the client’s needs.
  • Visit 2: Approximately 60–90 minutes
    • Review and/or cover sections and teach-backs in DHS’s Asthma Care: Your Guide to Managing Asthma, P-02168 (PDF) not covered during the first visit.
    • Complete the home walkthrough in the home setting or virtually using the CDC’s Home Characteristics and Asthma Triggers: Checklist for Home Visitors (PDF).
    • At the conclusion of home walkthrough, share relevant potential action steps listed on the checklist with client (parent/guardian if under 18).
• Durables: Use department funds, community benefit dollars, or philanthropic donations to purchase durables. These can include:
  • Allergen-impermeable mattress and pillow dustcovers
  • High-efficiency particulate air (HEPA) filtered vacuums
  • Integrated Pest Management (IPM) products
  • De-humidifiers, mechanical air filters/air cleaners
  • Asthma-friendly cleaning products and supplies

Asthma-Safe Homes Program measures

• ACT/TRACK: ACT or TRACK score at first visit and at three-month follow-up
• Asthma action plan: Does client have an asthma action plan? (at first visit and at three-month follow-up)
• Days absent from school/work: Number of days client absent from school or work due to asthma in last 12 months (at first visit) and in the last three months (at three-month follow-up)
• Emergency department (ED) visits: Number of ED visits in last 12 months (at first visit) and in last three months (at three-month follow-up)
• Enrollments: Number of clients enrolled in the Asthma-Safe Homes Program
• Follow-up contact: Number of clients who complete the program who receive follow-up at three months post-intervention
• Flu vaccine: Has client received a flu vaccine in last 12 months? (at first visit and three-month follow-up)
• Home visits: Number of clients who receive at least two home visits (complete educational program)
• Hospital visits: Number of hospital visits in last 12 months (at first visit) and in last three months (at three-month follow-up)
• Office/urgent care visits: Number of unscheduled office or urgent care visits for worsening symptoms in last three months (at first visit) and in last three months (at three-month follow-up)
• Primary care provider: Does client have a Primary Care Provider? If not, was client referred to a PCP? (at first visit and three-month follow-up)
• Referrals: Number of children and/or pregnant clients referred to the Asthma-Safe Homes Program who qualify for the program

Reporting template

Use or adapt this template to track client visits and outcomes for program reporting purposes.

Asthma home visiting program reporting template (Excel)