Table of Contents

• About This Manual
• Background
• Disparities in Health
• Barriers to Care
• Yes We Can Program Philosophy
• Elements of the YES WE CAN Approach
• Background on the Chronic Care Model
• System Change
• Clinic Change
• In the real world

• About This Chapter
• Population Management
• Medical Risk Criteria
• Social and Psychological Risk Criteria
• The Risk Stratification Pyramid
• Level 1: Self-Management Support
• Level 2: Basic Case Management
• Level 3: Moderate Case Management
• Level 4: Intensive Case Management
• Targeting the Right Population for Level 2 and Level 3 Interventions
• Levels of Care, Target Populations, Goals and Interventions Table

• About This Chapter
• Overview of the Medical/Social Model
• The Care Pathway
• Family-Centered Care
• Entry to and Exit From the Program
• Exclusion Criteria
• Exit Criteria
• The Asthma Team

• Getting Started
• Getting Support From Senior Leadership
• Asthma Oversight Group
• Key Staff for Starting the Program
• Organizational Chart
• Program Environment
• Footing the Bill
• Adapting the Program to Meet Local Needs and Resources
• Caring for a Diverse Population
• Take a Deep Breath

Getting Started

I. What is Program Monitoring and Why Do It?
• Who Are Your Stakeholders and What Do They Want to Know About the Program?
• What Data Do You Have or Can You Get?
• Types of Assessment
• Baseline and Goals
• Plan-Do-Study-Act

II. Monitoring an Asthma Program
• Medicaid Managed Care
• Quality of Care
• Patient Outcomes and Program Effectiveness
• Quality of Life
• Resources

• What Is an Asthma Registry?
• Tips for Creating an Electronic Registry
• Inclusion Criteria for the Asthma Registry
• Registry Accuracy
• Validate Your Registry
• Data Fields
• Maintaining the Registry
• Monitoring Reports
• Other Planning and Maintenance Considerations
• Get the Most From Your Registry

• About This Chapter
• Estimating Staff Time and Caseload
• Responsibilities of All Asthma Team Members
• The Family
• Staff Qualities
• Job Descriptions

• About This Chapter
• Staff Training and Orientation
• Case Conferences
• Team Meetings
• Managing the Team
• Competency Checklists

• Program Space
• Computer Equipment
• Medical Equipment
• Supplies
• Provider Materials
• Patient Education Materials
• Community Health Worker Materials
• Telephone System
• After Hours Coverage
• Outgoing Phone Mail Messages
• Staff Schedules
• Asthma Clinic
• Scope of Practice for Registered Nurses
• Scope of Practice for Community Health Workers
• Documentation
• E-mail to Families
• E-mail to Other Providers
• Fax and Regular Mail
• Guidelines for Interpreter Services
• Child Abuse Reporting Requirements for Health Practitioners
• Managing Insurance and Reimbursements

• About this Chapter
• Identifying Partners
• What Do You Have to Offer These Partners?
• Translating Good Feelings Into Genuine Support
• Thinking Strategically
• Asthma Coalitions: What’s an Asthma Coalition?
• When Not to Build a Coalition (and When You Probably Should)
• Transforming Community Partnerships Into an Asthma Coalition

• Implementation Checklist

• About This Presentation
• Presentation Slides