Community-Clinical Linkages for Asthma Care November 10, 2016 Community-Clinical Linkages for Asthma Care

Beginnings CHA Board of Trustees statewide health improvement project Community-Clinical Linkages for Asthma Care Beginnings CHA Board of Trustees statewide health improvement project An examination of hospital utilization data, hospital community health needs assessment results, the state health improvement plan, and Medicaid utilization data showed asthma to be a common and persistent health issue, disproportionately affecting certain populations. Asthma affects quality of life for children and adults throughout the state. Asthma is associated with significant health disparities.

Community-Clinical Linkages for Asthma Care Goals and Vision Goals Improve access and appropriate care by partnering with the community Reduce asthma hospitalizations and ED visits Significantly advance progress toward health equity for asthma care and outcomes by 2017 Vision No one should die of asthma or be required to limit his or her life unnecessarily due to the disease.

Community-Clinical Linkages for Asthma Care Developing the Model During 2015, worked with clinical experts, asthma program leaders, state and community organization partners to discuss needs/issues and begin structuring the Connecticut Asthma Initiative (CAI) Planned evidence-based interventions related to medication use, discharge and asthma action plans, follow-up primary care, and referral to resources Determined hospital-community partnerships as structure/model for implementation

Community-Clinical Linkages for Asthma Care Infrastructure Developed infrastructure – website, social media, ongoing meetings, and sharing of knowledge Conducted focus groups with key populations Worked in partnership with state agencies – Department of Public Health, State Department of Education, Department of Social Services

Community-Clinical Linkages for Asthma Care Website- ctasthma.org

Community-Clinical Linkages for Asthma Care Website – ctasthma.org

Community-Clinical Linkages for Asthma Care Focus Groups Conducted by the Hispanic Health Council with parents of children and adults affected by asthma in African American/Black and Latino communities in Bridgeport, Hartford, and New Haven Themes - Cultural issues, language barriers - Housing issues - School issues – environmental and clinical management - Emotional/psychological – challenge of managing child’s asthma - Smoking - Availability and awareness of services and resources

Community-Clinical Linkages for Asthma Care Interventions Medication: Staff Training, Patient Teaching, Patient Teach-Back Asthma Emergency Department Visit Discharge Plan and Asthma Action Plan Warm Hand-Off to Primary Care Provider

Collaborative Learning Community-Clinical Linkages for Asthma Care Collaborative Learning Presentations and facilitated discussions - Clinics and programs - Resources for patients and providers - Intervention implementation approaches, best practices, and successes - Hospital-Community Partnership models and roles - Environment – schools and home - Health equity - Social determinants

Community-Clinical Linkages for Asthma Care Measures Special data tools and templates accessible to hospital ChimeData Users CHA tracking statewide hospitalizations and ED visits, by race, ethnicity, and payer Process measure scorecard

Social Determinants of Health Community-Clinical Linkages for Asthma Care Social Determinants of Health Turning attention to social determinants of health and the need for systems change/policy issues to be addressed Areas of focus identified - Asthma Action Plan (AAP) with medication authorization - School nurse connection - Primary care with follow up - Community Health Workers - Home visiting support - Environment

Health Equity/Asthma Policy Summit Community-Clinical Linkages for Asthma Care Health Equity/Asthma Policy Summit

Going Forward Continued work with Hospital-Community Partnerships Community-Clinical Linkages for Asthma Care Going Forward Continued work with Hospital-Community Partnerships Further exploration of policy issues and avenues for systems change to address social determinants and to support clinically and cost effective models of care

Community-Clinical Linkages for Asthma Care Questions? Thank you!