1. Coalitions: Integrating Community-Based Asthma Control Strategies Jim Krieger, MD, MPH Robert Groves, MA, MPH Marielena Lara, MD, MPH Kimberly Wicklund, MPH November 2003

2. Concepts of Integration Service coordination –Providing asthma services coherently and consistently –Linking providers to assure delivery of full range of services Cross-institutional Collaboration –Developing a shared vision –Sharing resources –Joining in program implementation and advocacy Multi-disciplinary Collaboration

3. Families Want Integration “ Nurses, doctors, and parents need to connect. We all want to be involved and we want to know what’s going on with our kids.”

4. Primary Care Providers Want Integration Don’t know when kids admitted to ED or hospital Don’t know if medications are refilled Aren’t connected to schools and childcare

5. Barriers to Integration Structural –Silos –Staff not available to participate in integration work –Leadership not available to provide direction Cultural –Doing it your way –Turf and control Logistical –Working out the details –Communicating and coordinating are time- consuming Pressures to generate revenues, meet performance targets

6. Paradox of Integration While an integrated system will ultimately be more efficient and effective, getting there takes time and may appear inefficient

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

8. Coalition Membership Please circle the category (organization) that applies to you CSAS N=294

9. Coalition Membership Groups not well represented CSAS N=294 Other includes media, business, faith- based, housing, elected officials and staff

10. Coalition Membership Does the coalition have sufficient representation to accomplish objectives? –Yes: 70% –Range: 33-90% CSAS N=294

11. Overcoming Barriers: 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

12. Overcoming Barriers: Steering Committees Managed Care Organizations Medicaid Program Hospitals Emergency Departments Clinics Physicians Community Health Workers Nurses Universities ALA AAFA CBOs Community Asthma Programs Community Residents Faith-based Organizations School Districts Coalition Staff Public Health DHHS

13. 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

14. Philadelphia Link Line

15. 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

16. Care Coordination Alianza, Puerto Rico Nurse clinical coordinator respected and accepted by community works with community health care workers to coordinate care links patients with MCO, local and state health departments, and other agencies of the coalition.

17. Cross-Project Integration Group King County Asthma Forum Single asthma referral phone number Staffed by community health workers Refer to coalition member services –home visits (Allies, Healthy Homes, MHE) –public health nurses –primary care –family education groups Triage protocols Joint outreach and recruitment

18. Integration Across Organizations Community Asthma Action Plan –Summary of shared vision –Developed in a participatory, collaborative process –Defines roles Develop 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

19. Integration Across Organizations Asthma team Common tools, guidelines and messaging –Single asthma action plan –Shared educational resources and programs –Consistent asthma control protocols and guidelines –Consistent key asthma messages

20. Integration Across Organizations Linking Providers and CHWs King County –Learning Collaborative –Quality Improvement (Improvement Model) –Registry prompts –Systematized referral and communication Long Beach –Provider education (PACE) –Fax referrals to CHWs

21. Integration Across Organizations Coordination of Asthma Policy/Advocacy Long Beach –Better Housing: Providers and Landlords –Cleaner Air: Parents, Residents, Legislators, Schools, Environmental Groups King County –Public Housing –Medicaid reimbursement

22. Future Directions Integrating beyond asthma –Tobacco control –Other chronic conditions: STEPS Policy and advocacy Bringing to scale Sustaining integration

23. 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.