Coalitions: Integrating Community-Based Asthma Control Strategies Jim Krieger, MD, MPH Bob Groves, MA, MPH Marielena Lara, MD, MPH Kimberly Wicklund, MPH April 2004

Concepts of Integration Service coordination Consistent and coherent services Linkage and cross-referral among providers Cross-institutional Collaboration Shared vision Shared resources Exchange of data Coordinated/joint program implementation United advocacy Multi-disciplinary Collaboration

Ladder of Integration Joint Action Coordinated Action Cross-Referral Joint program development Coordinated Action Coordinated but independent components Joint: Agencies interested in asthma education design single program Coordinated actions: Quality improvement collaborative Cross referral: CHW to Primary care; Primary care to community education and support programs, education/support to CHW Mutual awareness: directories, shared information Cross-Referral Independent programs refer clients to each other Mutual Awareness Programs aware of one another

Barriers to Integration Structural Silos Staff not available to participate in integration work Leadership not available to provide direction Cultural and Personal Doing it your way Turf and control Logistical Working out the details Time for communicating and coordinating Fiscal Pressures to generate revenues Competition Proliferation of action plans Development of disease management systems by health plans independently of providers Reluctance of providers and CBOs to change current practices to conform with standardized guidelines High value on organizational autonomy

Overcoming Barriers: Coalitions Bring Together Sectors Safe, neutral space Forum to network and learn Common vision Leadership Coordination of resources

Overcoming Barriers: Coalition Steering Committees Primary mechanism for integration Decision-making body of coalition Gathering of organizational decision-makers Champion for integration Strategic planning Collaborative approach to grant-writing and new program development Champions for integration Need few people committed to integration, determined to keep it going Collaborative program development KC: EPA grant links childcare provider training with AAA CHWs Members Managed Care Organizations Medicaid Program Hospitals Emergency Departments Clinics Physicians Community Health Workers Nurses UniversitiesALA AAFA CBOs Community Asthma Programs Community Residents Faith-based Organizations School Districts Coalition Staff Public Health DHHS

Integrating Care For Individuals Community Health Workers Link families with schools, childcare, health providers, public housing Advocate for families for accessibility and consistency of services Care Coordinators Facilitate access to services Coordinate services across service providers Back-up CHWs Individual Asthma Action Plans

Philadelphia Link Line STEP 1- REFERRALS Family consents to Service Referrals made by Hospital Emergency Department, Schools, Community Organizations, Primary Care Providers or Self Referrals Consent and Patient Demographics sent to Asthma CALL Center via confidential FAX or Brochure STEP 2- CALL CENTER SERVICE .Intake form received and information logged into computer .Power Pack of asthma literature sent to family by mail .Care Coordinator contacts family member and conducts a telephonic needs assessment (60 item questionnaire) .Care Coordinator determines barriers to care makes recommendations for programs/services available that address their needs .Care Coordination and Family member develop a verbal action plan with list of resources they can be linked to for care .Client information logged into computerized database STEP 3- FOLLOW-UP Information from client encounter sent to Managed Care Asthma Disease Case Manager or other service provider with reciprocal agreement Follow up calls with family every month for 4 months

Care Coordination/Case Management Fight Asthma Milwaukee ED or clinic notifies care coordinator at local health department Coordinator arranges linkage to appropriate services Home visits by nurse case manager: Home visits by health department environmental inspector Calls to encourage follow-up with medical home Refer to parent mentor program Refer to family asthma education Info about childcare/school asthma education Shared evaluation and educational protocols

Integration Across Organizations Community Asthma Action Plan Summary of shared vision Developed in a participatory, collaborative process Defines roles Multiple forums to foster integration Coalitions as the overarching roof Cross-project coordination groups Learning collaboratives for clinics Joint proposals and projects Conferences and community meetings

Integration Across Organizations Common tools, guidelines and messaging Single asthma action plan Shared educational resources and programs Consistent asthma control protocols and guidelines Consistent key asthma messages Asthma Team (Long Beach): Parents, teachers, coaches, providers, etc…use coalition to change expectations for asthma care and help team members understand roles and responsibilities. Integrated education: Philly: integrate asthma 101 and smokeless home presentations KC: integrate asthma 101 into childcare trainings

Integration Across Organizations: Sharing Data and Information Health Plan Data Utilization/Registries Pharmacy ED Data Utilization Provider Data

Integration Across Organizations Coordination of Asthma Policy/Advocacy Better Housing Breathe Easy Units Cleaner Air Diesel Reimbursement Community Health Workers Chronic disease management Asthma education

Examples: Link clinics and schools via CHW Link clinics to commuity resources (classes and CHWs) Link health plans and clinics for QI Link childcare providers to public health for education and indoor env. assessments

Fight Asthma Milwaukee

Future Directions Policy and advocacy Bringing to scale Sustaining integration

To conclude: Integration doesn’t come easily but there are effective strategies to help get there. Paths to integration will vary by community and must fit the local landscape. “unnatural act among non-consenting partners” Thank you and I look forward to hearing about the all the experiences you have had in walking down this road.