Community Coalitions: Washington, DC

doctor and girlNational Capital Asthma Coalition

Epidemic

The nation’s capital has one of the nation’s highest asthma rates, particularly among children. Nearly 12 percent of the District’s children suffer from asthma, and in the late 1990s, several died from asthma each year. When the founding members of the D.C. Asthma Coalition convened in 1999, they identified critical gaps in delivering quality care to children with asthma. A disproportionately high number of families used the emergency department instead of primary care to treat children’s asthma. Many providers had not yet been trained in the latest asthma management guidelines from the National Heart, Lung and Blood Institute.

Support from the Robert Wood Johnson Foundation in 2001–2004 enabled the fledgling coalition to spread its wings. Today, the organization boasts more than 300 members from more than 70 organizations. Together, these individuals have begun to weave asthma policy planning and prevention into the fabric of District life. From the department of health and school district to the District’s many hospitals, health centers and Head Start programs, all of the key organizations that touch children’s lives come together to plan for and protect children with asthma.

A Team Approach Creates a Continuity of Care

To target its efforts, the National Capital Asthma Coalition (NCAC) began by mapping the District’s asthma epidemic. This exercise revealed that the parts of the District with high concentrations of poverty, poor access to primary care and environmental risks have the highest rates of childhood asthma. Reviewing hospitalization data, executive director Lisa Gilmore saw hot spots: neighborhoods with the highest pediatric asthma morbidity. She identified three areas—Marshall Heights, Congress Heights and Columbia Heights—where, using a collaborative case management process, teams would come together to support families struggling to control children’s asthma.

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NCAC Collaborative Demonstration Project teams organized around areas of the city with the highest rates of hospitalization for asthma.

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To meet the needs of families in these target areas, NCAC created and coordinated three interdisciplinary teams, each consisting of 12 to 14 physicians, clinic and emergency department staff, pharmacists, school nurses, child care providers, family case workers, community health workers and environmental specialists. The teams met every other week in three-hour facilitated sessions to develop asthma treatment plans for cases brought before each team by a physician or case manager.

By fall 2006, this team-based approach had evolved into a partnership with a consortium of local Medicaid managed care organizations and the District. The project’s Phase II will organize hundreds of community-based primary care and human services providers into interdisciplinary referral care teams, and transition the teams onto an interactive, electronic collaborative care coordination system to provide intensive collaborative care case management, particularly for high-risk patients. The system also will enable the tracking of both care and costs. The project goal is to bridge the gap between acute episodic care and long-term asthma management in children, reducing acute care costs by 30 percent.

Setting the PACE

As Gilmore knew, adherence to asthma treatment guidelines requires effective communication between physicians and families. She adopted the Physician Asthma Care Education (PACE) program, which has been found in published studies to enhance such communication, leading to significant reductions in emergency department visits and hospitalizations.

NCAC now has become a primary provider of professional training on asthma in the District. To date, NCAC has conducted seven PACE trainings with 255 physicians, school nurses and other health providers. The scope and scale of NCAC’s PACE trainings make the program one of the most serious attempts to train health care providers—especially school nurses—anywhere in the country. To recruit clinicians, NCAC partnered with key institutions for each seminar, including Howard University College of Medicine, D.C. Department of Health, Unity Health Care, Inc., Children’s School Services (D.C. school nurses), D.C. Chartered Health Plan, and Health Services for Children with Special Needs, Inc. Participants surveyed at each seminar registered very high levels of satisfaction; the majority rated PACE as “excellent” and indicated that it met stated objectives, was relevant to their practice or work and would improve their ability to provide excellent care.

To expand the reach of its professional trainings to more than 4,000 physicians and other clinicians across the District, NCAC has received funding from several sources to produce and distribute an expanded PACE program via CD-ROM and the Web. The accredited program will include additional modules to promote the standard asthma action plan, tobacco cessation and prevention of respiratory illness.

Unifying Standards

Thanks to the persistence of NCAC, working collaboratively with the D.C. Department of Health, D.C. Public Schools, and community partners, D.C. now has a law that allows students with a medication plan to possess and self-administer lifesaving asthma and anaphylaxis medications during school hours and at school-sponsored activities. Enacted July 26, 2007, the Student Access to Treatment Emergency Act of 2007 (A17-0082) applies to all D.C. public, private, charter and parochial schools starting with the 2007-2008 school year. Introduced by Councilmember David Catania, the bill received unanimous approval by D.C. Council members before being signed into law by D.C. Mayor Adrian Fenty. NCAC’s interagency school policy group continues to bring together D.C. Department of Health, D.C. Public Schools, D.C. school nurses, managed care organizations, hospitals, and community health providers to promote additional proactive policies to improve asthma care in schools and child-care agencies.

With this initial success under its belt, NCAC next turned to the larger issue of standardizing an asthma action plan for the District. In 2005, with four competing Medicaid MCOs in the room, as well as representatives from the school district, department of health and local health care institutions, NCAC staff expected a protracted struggle for agreement. “We knew that it had taken other coalitions several years to teach consensus on a standard asthma action plan,” recalls Gilmore, “so we were delighted to bring D.C.’s stakeholders to agreement in a single hour.”

In 2006, the D.C. Department of Health awarded NCAC a block grant to train administrators and staff at all 167 D.C. public schools on the policies and practices spearheaded by NCAC and to work with each school on the implementation of asthma management strategies. Combined with NCAC’s training of all 150 D.C. school nurses, NCAC’s Asthma-Friendly Schools Program reaches those on the ground in the institutions that touch children’s lives. “If asthma control can be understood and implemented in the public schools, the improvement in children’s lives will be immeasurable,” says Gilmore. “There’s no reason why we can’t offer every child with asthma in D.C. the opportunity to experience fewer symptoms and fewer limitations on their activities, particularly at school.”

Building Futures

After a successful transition from a grant program to an independent 501(c)(3) nonprofit organization, NCAC now serves as a major regional resource for asthma education and a model for institutional collaboration. “If NCAC has a major accomplishment, it’s been the coalition’s ability to bring organizations together around children’s asthma,” says Dr. Carlos Cano, senior deputy director of the D.C. Department of Health’s Maternal and Primary Care Administration. Today, multiple organizations come together to share data, research, educational materials, access to referral networks and other support in ways that would have been unthinkable previously.”

Gilmore and other NCAC members argue that spending on asthma education and early intervention ultimately pays for itself, and not just because it can reduce emergency department visits and hospitalizations. “Asthma control is crucial to the lives of so many families here,” says Gilmore. When a child’s asthma is controlled, parents miss fewer days of work and students miss fewer days of school. More students are ready to learn and be part of school life. “There’s no doubt in my mind that coalitions like ours save money for local businesses and health care organizations in the long run,” says Gilmore. “Few other forms of health care spending have such an impact, particularly when efforts are focused on low-income families.”


Summary

The National Capital Asthma Coalition, formerly the D.C. Asthma Coalition, works to build a sustainable system of care to reduce emergency department visits, hospitalizations and school absences, and to improve the quality of life for children and adults with asthma. Currently, NCAC works in three key strategic areas: a collaborative intervention demonstration project to improve care management and delivery for at-risk children, a professional and community education program, and coalition-building activities that enhance coordination, policymaking and resource-sharing.

NCAC boasts over 300 members from more than 70 agencies. Its strong, collaborative infrastructure includes the District’s hospitals that serve children, four Medicaid MCOs (AMERGROUP, D.C. Chartered Health Plan, Health Services for Children with Special Needs, Inc., and Health Right, Inc.), and community health centers. Its membership also includes representatives from the department of health, school district, universities, businesses, child-care providers, patient advocacy groups, environmental health programs, and neighborhood and community organizations.

Strategies and Programs

  • A common asthma action plan for the District of Columbia
  • Physician and school nurse asthma care education (PACE) training
  • New school district medication policies
  • An Asthma-Friendly Schools Training and Awards Program
  • A Collaborative Home Environmental Intervention Program
  • A Collaborative Intervention Demonstration Project
  • Educational workshops and presentations in the community

Children and Families Served

NCAC’s community outreach and education program reaches more than 6,000 District residents each year and many more will benefit from the recently introduced standardized asthma action plan developed with coalition partners. While NCAC focuses on educating the District at large, its multidisciplinary collaborative care case management teams have focused on areas where ZIP codes indicate the highest rates of hospital admissions for asthma: Anacostia, Columbia Heights, Congress Heights and Marshall Heights.

Results

  • Trained 255 health care providers through seven CME-accredited PACE seminars.
  • Trained 150 school nurses in the latest standards of asthma care.
  • Educated more than 6,000 District residents annually through 90 free asthma workshops and health fair exhibits each year
  • Helped shape and implement D.C. Department of Health’s strategic asthma plan through NCAC’s five committees.
  • Created interagency school policy group.
  • Launched A+ LIFE (Asthma Learning is For Everyone)©, a family asthma education program developed jointly with the District’s four Medicaid MCOs, National Capital Area Society for Public Health Education and National Children’s Museum.
  • Conducted two bilingual Asthma Fairs in Columbia Heights with over 200 Latino children and adults served at each event and distributed NCAC’s bilingual Asthma Resource Guide to improve access to services.
  • Launched partnership with EPA Region 3 and D.C. Public Schools to train and guide school teams on implementing EPA’s Indoor Air Quality Tools for Schools Program.

Lessons Learned

  • Work hard to establish consensus and trust, particularly among institutional stakeholders.
  • Allow for time in the early stages of the coalition to plan initiatives.
  • Use professional training and community education programs to market the coalition’s mission, increase awareness and spur demand for better asthma management across diverse audiences and programs.