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3.d.ii: Expansion of Asthma Home-Based Self-Management Program

Project ObjectiveImplement an asthma self-management program including home environmental trigger reduction, self-monitoring, medication use, and medical follow-up to reduce avoidable ED and hospital care.

Project DescriptionDespite best efforts of practitioners to implement evidence based practices, patients continue to have difficulty controlling their symptoms. The goal of this project is to develop home-based services to address asthma exacerbation factors. Special focus will be emphasized on children, where asthma is a major driver of avoidable hospital use.

 

PMO: 
Community Co-Lead: Scott Auwarter, BronxWorks
BLHC Co-Lead: Peter Sherman, MD

 

 

Jul 18, 2017

Project Update For February 2017

The Asthma workgroup continues to update and refine its project Operation’s Manual and protocols for referrals for home-based education, support, and/or environmental assessments.  ArchCare at Home and BronxWorks are collaborating on these efforts and have seen an improvement in patients accepting services. 

 

In order to track outcomes, the workgroup is partnering with BLHC IT to embed data points to track outreach efforts for patients with a recent ED visit and is continuing discussions with the Bronx RHIO to identify a platform that will track activities across partners .

 

BHA has signed an MOU with Collaborative for Children and Families (Children’s Health Home) regarding referring asthma patients to the health home.

 

As a new initiative, the workgroup is in discussions with pest management organization in order to integrate this service in the program.

Jul 17, 2017

Project Update For April 2017

As a new initiative, the workgroup is incorporating integrated pest management (IPM) services as part of the program. This service will be available to residents of the Bronx who are living with asthma and who have provided their consent to receive the services.

 

 

 

Sep 30, 2016

Project update for September 2016

The project workgroup has developed an asthma program, Breathe Better Bronx - along with promotional brochure which explains the various services available to the community. In an effort to engage patients, the Project team began sending engagement letters to patients who have had 4+ ER visits and 2 admission visits in the last 12 months.  As a result, a number of patients have called the care manager who was able to link them to Bronx Works for home visits.  The team recently added a care manager stationed at the BLHC ED who regularly educated patients about asthma and the DSRIP services. Bronx Works staff recently received training on how to enter and upload home assessment reports onto the patient’s Electronic Medical Record (EMR).  This will help facilitate a more seamless and cohesive provision of services from primary care and the community.