National Capital Asthma Coalition Coordinating Care and Systems for Sustainability

1. Schools Daycare Community Health Workers Pediatricians Clinics Emergency Depts. Collaborative Care Intervention Teams Face-to-Face and Online Care Coordination Pharmacies Environment Specialists Family Support Ctrs. Mental Health Agencies National Capital Asthma CoalitionCoordinating Care and Systems for Sustainability Based on collaborative intervention, data-sharing, and administrative protocols developed by frontline providers Policies Secured, real-time electronic data-sharing network • Children • with Asthma • and their Families • Access to Quality Care • Education • Self-Management • Skills Building • Home, School & Daycare • Asthma-Friendly • Environments Home visits Resources Collaboration Community Education and Outreach Resources Case Management Feedback Awareness Referrals Education, Advocacy Education Public Health Utility Systems Integration and Care Coordination • Bio-Surveillance • System linked to Dept. of Health’s • National Electronic Disease Surveillance System (NEDSS) • Single Point of Entry • Data Warehouse • Medicaid MIS • DC Primary Care Association’s • Medical Homes DC • To increase the capacity of safety net providers to ensure that District residents have access to quality primary care SURVEILLANCE

2. NCAC’s Collaborative Teams Mobilize Care in DC’s High Asthma Morbidity Areas DC Pediatric Asthma Hospitalization1 Rates2 – 2000 # Number of Pediatric Asthma Hospitalizations in DC1– 2001 5 # 10 10 H Note: Rankings are similar but not identical in 2000. 1 Source: District of Columbia Hospital Discharge Database. 2 Equals hospitalizations divided by 2000 Census population data by zip code in same age category. 7 9 H Team 2 9 7 5 4 8 6 H 2 2 Team 1 Columbia Heights 3 8 6 Marshall Heights 4 3 1 1 Congress Heights Team 3

3. NCAC Teams Are Local Resource Networks Team 1 - Marshall Heights 1. Chartered Health Plan 2. Chartered Family Health Center 3. CVS Health Connection 4. Edward C. Mazique Parent Child Center 5. East-of-the-River Family Support Collaborative 6. National Capital Asthma Coalition Comm. Health Wkr. 7. Primary Care Physicians 8. UDC-USDA Health/Environmental Services Project 9. Howard University Hospital Emergency Department 10. Children’s Hospital Emergency Department 11. Health Services for Children with Special Needs/ HSC Pediatric Center (Hospital for Sick Children) 12. Hunt Place Clinic 13. DC School Nurses 14. CVS Pharmacies • NCAC’s responsibilities: • Facilitate and coordinate teams. • Document collaborative care management process. • Train physicians in PACE (NHLBI guidelines). • Train/create certified asthma educators. • Track care (e.g., controller prescriptions filled, changes in practice, and outcomes). • Develop collaborative procedures (e.g., to coordinate use of written asthma action plans by M.D., child, family, pharmacist, school nurse, etc.) Team 3 - Congress Heights 1. Chartered Health Plan 2. Primary Care Physicians 3. UDC-USDA Health/Environmental Services Project 4. Far Southeast Family Strengthening Collaborative 5. National Capital Asthma Coalition Comm. Health Worker 6. Howard University Hospital Emergency Department 7. Children’s Hospital Community Clinic: Ward 8 8. Mid-Atlantic Center for Children’s Health & the Environment 9. Congress Heights Head Start 10. Unity Health Clinic: Southeast 11. Health Services for Children with Special Needs/ HSC Pediatric Center (Hospital for Sick Children) 12. Children’s Hospital Emergency Department 13. United Planning Organization 14. DC School Nurses 15. CVS Pharmacies Team 2 - Columbia Heights 1. Mary’s Center for Maternal and Child Care 2. Chartered Health Plan 3. National Capital Asthma Coalition Comm. Health Wkr. 4. UDC-USDA Health/Environmental Services Project 5. Columbia Heights/Shaw Family Support Collaborative 6. Primary Care Physicians 7. Howard University Hospital Emergency Department 8. Children’s Hospital Community Clinic 9. Children’s Hospital Emergency Department 10. Rosemont Center (Child Care) 11. DC School Nurses 12. CVS Pharmacies