At Children's, asthma continues to be the leading cause of hospitalizations. South Coast and Western MA have unique vulnerabilities for asthma exacerbations, including high levels of poverty.
Goals and Objectives:
Goal 1: Develop multidisciplinary workforce that fosters family-centered, culturally and linguistically appropriate asthma services in South Coast and Western MA. Objective 1a. CAI team members will provide training and shadowing opportunities to the replication sites. 1b. Work with pediatric providers within medical homes. Goal 2: Improve access to quality CHW asthma home visiting services for children through CAI replication at new sites. Objective 2a. Mentor PPOC practices in the South Coast and in Western MA in CAI model. 2b. Mentor the new site Clinical Directors and CHWs to provide case management services. 2c. Train new sites to provide home visits. 2d. Mentor the new sites to ensure the reduction in the number of asthma related exacerbations. 2e. Mentor the new sites to ensure the reduction in number of missed school days and parent/guardian missed workdays due to asthma. Goal 3: Improve health equity for underserved population by connecting them to services. Objective 3a. Empower families to advocate with landlords, health insurance, and pharmacies. Goal 4: Work with PPOC sites to ensure sustainable funding. Objective 4a. Obtain feedback from the CAI Community-Family Advisory Board (C-FAB). 4b. Work with accountable care organization (ACO) planners and payers to incorporate CHW asthma home visiting.
The Medical Home Asthma Program (MAP) will utilize the CAI model on the South Coast and in Western MA, to improve access to care, health outcomes and quality of life for children with asthma while also reducing costs. MAP will conduct Learning Communities with these practices' pediatric primary care providers in order to support enhanced population management and new services for children with asthma.
Collaboration with the Pediatric Physicians' Organization at Children's (PPOC) primary care sites in the South Coast and Western MA.
The new areas will demonstrate improved health outcomes, quality of life and Return on Investment (ROI), using CAI's evaluation approach. There will be a similar comparison population to compare health outcomes and costs, as well as changes in the rates of exacerbations and asthma medication ratios (AMR) before and after the intervention.