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

2. 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.

4. 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.

5. 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

6. 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

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

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

10. 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

11. 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

12. 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

13. 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

14. 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

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

16. 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

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