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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.

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

Mar 30, 2018

Winter 2018 Update

The Asthma workgroup meets regularly with partners from BLHC, Bronx Works, Urban Health Plan.  Two new RNs were recently added to the team to support ED admissions after 5 pm and medication adherence education.  In December, team members recently completed Asthma refresher training at the East Harlem Neighborhood Action Center (EHACE) on identification and management of indoor air triggers, medications used to treat and manage asthma, and methods to improve treatment adherence.

The BBB team has recently launched an outreach initiative aimed at proactively connecting asthma patients to primary care and preventive care.  Given the recent flu outbreak, this work is very relevant and timely as we the flu can be further complicated by asthma. The BBB team continues to work in close collaboration with the Care Transitions Team to connect patients with asthma education and environmental home-based assessments post-discharge.  The BBB team is also working in close collaboration with the new Pharmacy Initiative to support education on medication management and connections to local pharmacies.

Nov 13, 2017

Fall 2017 Update

As of DY2Q4, the Asthma project has completed 75% of project milestones.

The workgroup continues to meet regularly to identify successes, challenges, and continuously improve services implemented to our community.

The workgroup recently approved a flier to be distributed to partners interested in referring eligible patients. Patients would be enrolled into Breathe Better Bronx, a no-cost program that helps people in the South Bronx control their asthma through asthma treatments, home-based services, and education. Breathe Better Bronx Asthma Care Team members offer support services for managing asthma in adults and children. These include:

  • Phone calls from an Asthma Care Team member to monitor symptoms and schedule medical appointments
  • Up to 3 home visits per year to find and get rid of asthma triggers
  • Finding pharmacies that take client’s insurance
  • Education about medication

To refer a patient to Breathe Better Bronx, please contact:
Certified Asthma Educator (Eng, Spa) 347-558-5471
Community Health Worker (Eng) 347-268-4449

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.