YES WE CAN Children’s Asthma Program

This case study was prepared for CDC by Dr. LaMar Palmer of MAS Consultants. The purpose of the case study is to share the experience of one community as they attempt to address the problem of asthma. It does not represent an endorsement of this approach by CDC.

YES WE CAN Children’s Asthma Program: The YES WE CAN Toolkit

A YES WE CAN "Toolkit" has been developed for distribution to those health care providers wishing to replicate a pediatric asthma program in their clinics. The Toolkit describes how to set up, implement, and maintain a program in any community clinic using a population-based approach. The Toolkit consists of three fully developed manuals of instruction, more than 1,600 pages of guidance on "what to do" and "how to do it." They represent years of thought, planning, development, and documentation of all the processes used in the program. These manuals were developed over a period of more than two years. They incorporate the best practices from the demonstration project and the lessons learned from five years of program implementation. The experience and expertise upon which the Toolkit is based also comes from the experiences of nearly 40 asthma care managers at KP/NC. Since 1998, these managers have handled the care of approximately 26,000 members who are at high-risk from asthma. A great deal of the detailed information in the clinical care manager manual and the implementation manual comes from the KP experience. Community Health Works experiences and expertise with YES WE CAN and the community health workers program form the base for the community health worker manual.

A risk stratification model is provided to identify levels of risk for children who have asthma and to suggest services and interventions to address the needs for these children and their families. The Toolkit describes the medical/social team-based model of care, the program interventions, and family flow through the program. The manuals contain protocols, documentation forms, tools, sample scripts, and sample letters for patients and primary care providers. Users will find sample job descriptions and interview questions, professional competencies required by asthma team members, and information about how to build a successful asthma team.

Kathryn Graham, Regional Health Education Program Coordinator for KP/NC and lead author of two of the toolkit manuals, described them in the following way. "The three manuals in the Toolkit combine a wealth of knowledge, experience, and expertise from a successful community partnership of organizations working together toward a common goal to improve the health of our children and families living with asthma. The YES WE CAN model combines learning from implementing a large-scale population based model (KP, Northern California) and the learning from community models (YES WE CAN asthma clinics, the Odessa Brown asthma clinic in Seattle) that successfully address the social needs of complex families with asthma by using community health workers. The blending of the two results is an exciting approach to improving the quality of asthma care for low-income inner-city families."

Chapter titles from the YES WE CAN Toolkit

• Volume One: Program Implementation Manual (350 pages)
  1. Introduction
  2. Population Management
  3. The YES WE CAN Medical/Social Model
  4. Getting Started
  5. Program Monitoring
  6. Creating an Asthma Registry
  7. Staffing: Roles, Caseload and Job Descriptions
  8. Staff Training and Management
  9. Operational Issues
  10. Community Partnerships and Coalitions
  11. Implementation Checklist
  12. Power Point Demonstration
  13. Professional Resources
• Volume Two: Clinical Care Manager Manual (434 pages)
  1. Introduction
  2. Population Management
  3. YES WE CAN Medical/Social Mode
  4. Referral and Outreach Process
  5. YES WE CAN Pathway
  6. Asthma Clinic
  7. Home Visit
  8. Telephone Assessment Calls
  9. Program Exit
  10. Case Management
  11. Self-Management Education
  12. Promoting Behavior Change
  13. Caring For a Diverse Population
  14. Operational Issues
  15. Sample Forms, Letters, Handouts, and Brochures
  16. Professional Resources
• Volume Three: Community Health Worker Manual (869 pages) – available in English and Spanish editions
  1. Introduction
  2. What is Asthma: Asthma and Your Body
  3. Asthma and Your Community
  4. Asthma and Your People Skills
  5. Working With families
  6. Resources: Know What To Do
  7. Check What You Know

Each Toolkit includes the three manuals and a shelf library of additional resources. The California Endowment and KP/NC funded this edition for no-cost distribution to institutions in California who care for the Medi-Cal population. The Toolkit is no longer available. Community Health Works also assembled a set of articles presenting evidence for chronic conditions management in general and from the San Francisco demonstration project specifically.