1. Evaluating and Sustaining Structural Changes Advocated for by the San Francisco Asthma Task Force and Its Partners: Using Information Technology to Monitor Children and Youth with Asthma in an Urban School District
Gloria Thornton, Blue Cross of California State-Sponsored Business
Karen Cohn, San Francisco Department of Public Health
Stephanie Manfre, Breathe California

2. Background
At least 10% students in SFSUD schools (K-12) and Child Development Centers diagnosed with asthma
2002: Crisis prompted strategic action for structural change--two tragic deaths of SFUSD students due to asthma
2001: SF Board of Supervisors ordinance establishes advisory Asthma Task Force; School Health Programs manager an early partner and member
2003: SFATF Strategic Plan identified asthma education and improved facilities as School/ Child Development priorities
Superintendent creates District Asthma Team (DAT) to work with ATF
The San Francisco Board of Supervisors Asthma Task Force (SF ATF) was legislated in 2000.
Approximately 10% of children and youth attending schools (K-12) and Child Development Centers run by the SFUSD have been diagnosed with asthma. This is probably a low estimate.
The head of the School Health Office is a non-voting member of the SF ATF and an early partner. Work to improve conditions at SFUSD sites, as well as asthma education has always been a SF ATF priority.
In 2002 there were three tragic deaths of students related to asthma. This was clearly a crisis that prompted strategic action for structural change.

3. Learning the Hard Way
A four-year-old child died from asthma while in the care of his SFUSD Child Development Center:
Staff did not know the child had asthma
The symptoms were not consistent with what lay persons would easily identify as "an asthma attack”
The child was young and did not have a lot of expressive language to communicate the nature of his distress
The tragic death of a 4 year old child at one of the SFUSD’s Child Development Centers illustrates some of the complexities of the problem
Staff did not know the child had asthma.
The symptoms were not consistent with what lay persons would easily identify as "an asthma attack”
The child was young and did not have a lot of expressive language to communicate the nature of his distress.
It became clearer after this tragedy that it was absolutely necessary to identify asthmatic children.
To educate staff about how to respond to an asthma crisis
To have a treatment plan that could be initiated before the arrival of paramedics.

4. Call to Action
It became clearer after this tragedy that it was absolutely necessary:
To identify asthmatic children
To educate staff about how to respond to an asthma crisis
To have a treatment plan that could be initiated before the arrival of paramedics
To use District Asthma Team (DAT) to spearhead action

5. Components of the Problem
Lack of communication about chronic health problems between families and schools
No formalized protocols for identification of students with asthma or provision of emergency treatment
Lack of staff training on asthma emergency response
Absence of linkages with medical providers in the community
Asthmatic children were not formally identified.
There were no formalized mechanisms for documented emergency treatment protocols for asthmatic children and youth.
There was a lack of communication between parents and schools/child development centers about chronic health problems.
Lack of knowledge about asthma and emergency response by staff.
Medical providers were not viewed as partners.

6. Collaborative Partnership
Asthma Task Force, School Health Programs
& District Asthma Team (DAT)
Policy Development: Board of Education Resolution for Emergency Care Plans
DAT designs Asthma Emergency Care Plan and implementation strategy
Site-level data entry required to use District-wide Student Info System (SIS)
Site staff educated on role
The SF ATF worked with the SFUSD School Health Office and the District Asthma Team (DAT) created by the superintendent to identify asthmatic students and create a formal asthma emergency care plan.
The collaborative partnership decided to take a top down approach seeking a policy to mandate implementation.
The policy was passed by the Board of Education in May 2004.
The plan was ambitious and much of the work was done by the SF ATF.
It required designing and agreeing on the form including entry into an electronic data base and multi stakeholder education. Because of state regulations 2 forms, one for med use and the care plan were required.

7. Potential Uses of SIS as a Health Records Technology
To identify which children have asthma, in case of a medical emergency
To prioritize schools needing student asthma education, school nursing support and facilities improvement

8. Asthma Emergency Care Plan Implementation
Education of District Administration
Education of K-12 School Staff and CDC Staff
Education of Parents and Guardians
Education of Students
Education of Community Medical Providers
Need for Buy-in/ Ownership
Acceptance of Value of Care Plans
We learned that medical providers did not always recognize the value of the care plans
Those that did often confused them with asthma action plans
Parents required education
School staff at all levels needed education
School site buy-in was inconsistent

9. Implementation Complexity
Two Different Forms Required by Regulation
Concerns about Violation of Privacy
Concerns about Additional Paperwork
Concerns about Value and Usefulness
Concerns about Time for Data Entry
Parents/Medical Providers had a difficult time following through

10. Opportunities
Development of Fliers and Posters to Educate and Increase Awareness of Parents, School/CDC Site Staff, Students and Community Medical Providers
Increased Intensive Targeted Education
Continual Ongoing Strategy Development with DAT and School Health Program Office Partners
Medical providers began to be familiar with the forms
More forms were received by schools (anecdotally)
School secretaries continue to de-prioritize data entry.
The goal is to put the forms in the child’s file and enter into the data base.
The data component of the goal continues to be elusive.
Monitoring by school IT shows very little data entry
Concern about asthma prompted concern about other chronic conditions. 10

11. Site Buy-in and Implementation Vary Widely:
Challenges
Site Buy-in and Implementation Vary Widely:
School secretaries find data entry a serious burden and continue to de-prioritize data entry
The data component of the goal continues to be elusive; monitoring by District IT shows very little data entry and need to expand data fields for collection
Conclusion: Change is a multi-step process in a large system. Evidence of success is needed to sustain programmatic effort
To implement the project two forms had to be filled out and signed by medical provider and parent/guardian
The Asthma Emergency Care Plan and a Medication Form
Parents had a difficult time following through
School implementation varied from site to site in the K-12 setting
Medical providers required on-going education
School secretaries found data entry a serious burden
There was buy-in from the Board of Education and School Health Office
Site specific buy-in was spotty
We learned that a top-down approach has limitations 11

12. Sustainability Strategy: Ownership & Perception of Value are Key
Ownership at School Site:
ATF posters on the walls
Correct forms available to parents
Data entered into Student Info System database
Inclusion of school nurses in provider outreach
Ownership at District Level:
Centralized data analysis
DAT strategy response to data analysis
Accountability through periodic reports to Board of Education
Use of district-wide health records technology (Student Information System) to track students at risk
Accountability through Board of Education Report
Ownership at School Site:
ATF posters on the walls
Correct forms available to parents
Data entered into SIS database
Inclusion of school nurses in provider outreach
Ownership at District Level:
Centralized data analysis
Response to analysis from DAT/strategy development 12

13. Evaluation of Effectiveness
Examine assumptions and operational knowledge early on
Set evaluation criteria early on
Re-evaluate on a regular basis
Ensure top down buy-in and have a back up plan for change in personnel
Do the work to also get buy-in at the site level, from the ground up, and within community
Be open to continued Learning from on-going challenges
Examine assumptions and operational knowledge early on
Set evaluation criteria early on
Ensure top down buy in and have a back up plan for change in personnel
Do the work to also get buy in at the site level, from the ground up 13

14. Having Technology Available Does Not Guarantee Its Use
A policy and buy-in at top levels does not guarantee consistent implementation;
Implementation is influenced by ownership of process;
Implementation is effected by perceived value of intervention;
Need to be receptive to concerns and ideas of those essential to the success of the intervention;
We cannot use health records technology to measure the impact of our activities without data entry resources and cooperation at the individual school sites
We cannot sustain a programmatic effort without evidence of successful implementation
We have to continually educate all the involved parties
A top down approach does not guarantee immediate success when there is so much inconsistency at the individual site level
Additional resources are needed for data entry.
Change comes slowly and our non IT strategies work
Empowering staff at all levels to be successful is a slow, but worthy approach to building will and further success and ownership 14

15. We cannot use health records technology without data entry resources;
Additional data entry resources are crucial;
Continual on-going education of all essential partners/audiences is necessary;
What seemed like a small intervention is actually a much larger enterprise involving a large multi-component system and several community groups (parents and medical providers) not officially a part of that system;
Change comes slowly and alters the culture of the system and those who interface with it.

16. Our Goal Remains Within Reach16