THEME 4: Coalitions and Policy Change

    • October 1, 2008

Creating Standardized Asthma Action Plans
One barrier to improved pediatric asthma control in Philadelphia's high-risk neighborhoods was the absence of a standardized asthma action plan for the three Medicaid managed care organizations in the city. A action plan, developed by the health care provider to help parents manage their child's asthma, identifies early warning signs of an attack, outlines recommended doses and frequencies of medication for quick relief and long-term control, and provides emergency contact information.

Filled out by the health care provider, an asthma action plan is a key management tool. Based on symptoms, it sets benchmarks that help parents know which asthma medicines to give, how much and when, and at what point to seek immediate medical care.

Without standardization, Philadelphia families with pediatric asthma encountered different kinds of asthma actions plans as they moved from one Medicaid plan to another—a common occurrence.

The changes in asthma action plan format and information left parents confused, and as a result many simply disregarded their child's plan, says Robert C. Richardson Jr., asthma control program administrator in the Pennsylvania Department of Health.

In response, Philadelphia Allies Against Asthma—a local coalition that was part ofAllies Against Asthma, a national program of the Robert Wood Johnson Foundation (RWJF)—formed a workgroup to develop a standardized asthma action plan. The Allies coalition represented some 40 organizations, including health care systems, providers, schools and insurers.

"The coalition provided a structure to bring together three competing Medicaid managed care organizations to work toward a common goal [a common asthma action plan]. This would have been unlikely without the coalition," says Amy Friedman, MPH, deputy director of the national Allies program.

The result was a single form—in English and Spanish—that the three managed care organizations adopted and disseminated to some 600 providers in their networks. In addition, the coalition and other organizations disseminated the form widely, sending more than 10,000 copies to nursing centers and clinics plus posting it on the website of the Health Promotion Council of Southeastern Pennsylvania, which convened the local Allies coalition.

Coalition members also helped promote the use of the standardized asthma action plan. For example, the Community Asthma Prevention Program at Children's Hospital of Philadelphia, a key coalition member, encouraged the plan's use by public schools and primary care providers. The Pennsylvania Department of Health used the plan as a statewide model.

The standardized asthma action plan and the process that led to it illustrate how the Allies Against Asthma coalitions employed collaboration to affect health care policy. "There's an ability to be strategic in dealing with policy change," Richardson says of the coalition approach. "There's strength in numbers, especially if everyone's on the same page."

In Virginia, the Hampton Roads Allies coalition also created a standardized asthma action plan. Hampton Roads, the southeastern coastal tip of the state, encompasses Norfolk and six other cities. The Consortium for Infant and Child Health, a regional coalition, runs the Hampton Roads Allies project.

The region's providers were using many action plans—some good, some not so good, says Frances Butterfoss, PhD, co-director of the Allies project and a professor in the pediatrics department of Eastern Virginia Medical School in Norfolk.

The diversity caused confusion, especially among school nurses trying to track asthmatic children enrolled in different plans, according to Butterfoss. She rates development of the unified form as probably the most important result of the Hampton Roads Allies project.

Working through the coalition, all seven school districts in the area endorsed the standardized plan, and the Virginia Asthma Coalition recommended its use statewide and posted it on the organization's website.

Fostering a Healthier Environment
In California, the Long Beach Alliance for Children with Asthma, the local Allies coalition, worked to change environmental policies as a means to improved asthma control.

"The interface between asthma and the environment is undeniable," says Elisa Nicholas, MD, MSPH, founder of the allianceand director of the Allies project. "Our work with asthma has required that we focus on the environment in which our children live, learn and play." Nicholas is chief of staff of Miller Children's Hospital and CEO of the free-standing Children's Clinic.

Nicholas cites studies linking air pollution—particularly pollutants associated with cars and trucks—to increased risk of asthma. For example, University of Southern California researchers have reported that the closer children live to a freeway, the more likely they are to be diagnosed with the disease.

The alliance, which includes participants from government and service agencies, health care organizations and grassroots groups, initially focused on opposing the planned expansion of Interstate 710 through inner-city Long Beach. In addition to impacting air quality, the work would have entailed condemnation of hundreds of homes and businesses.

The alliance helped mobilize parents of asthmatic children living near the freeway to speak out in opposition and, in conjunction with similar efforts by others, helped stop the project.

The organization is now participating in a lengthy public process aimed at producing a more acceptable, less intrusive I-710 improvement program. It is also working to stem other sources of air pollution, especially those associated with the busy Long Beach port.

More recently, the alliance expanded its policy work to housing issues, becoming part of an umbrella coalition pushing for a special fund to finance construction of low-income units.

Beyond Long Beach itself, the organization was active in Los Angeles County, of which the city is a part. The alliance helped the Asthma Coalition of Los Angeles County develop a policy paper on a range of steps for improving asthma outcomes countywide—from providing higher quality health care to adopting lower-emission technologies. (Controlling Asthma in Los Angeles County: A Call to Action is available online.)