Boston Children’s Community Asthma Partnership

Connection to Moving Healthcare Upstream

The Children’s Community Asthma Partnership (CCAP) serves as the anchor organization for the Moving Health Care Upstream team in Boston, Massachusetts. The CCAP is improving pediatric asthma care by identifying and addressing socio-economic, medical, and environmental factors that impact health. The Partnership offers proactive solutions to improve a family’s asthma care and connect them with the social and family services they need.

Our Community & Our Need

Asthma is a widespread chronic disease and a leading cause of emergency room visits and missed school days in the Boston community. Asthma is also more prevalent in children from low-income neighborhoods and among Latinos and African Americans, whose rate of hospital admission is three to five times higher than for white children. The social determinants of health, including family finances, transportation, housing quality, and education often overwhelm the health and wellbeing of families and 96% of asthmatic patients have one or more unmet family need. The CCAP is working to identify patients and families at risk for uncontrolled asthma and develop collaborative systems to support families to overcome these barriers.

Our Solutions & Our Community Partners

The partnership utilizes population health management methods including the development of a registry to identify patients with asthma, assessment of medical and social risk and development of standardized care bundles to provide consistent, quality care. All methods focus on prevention, risk stratification, proactive outreach and follow up, and are team-based and patient-centered.

Through quality improvement and technical assistance Dimock and South End community health centers, have effectively implemented asthma population management programs into their clinical process flows. These programs have worked to identify at risk patients and deliver standardized medical and social care bundles for all asthma patients. The percentage of asthma patients with low Asthma Control Test scores has decreased and the health centers have seen an increase in the use of individualized asthma action plans and referral to community agencies. Implementation of care bundles was enhanced through newly designated roles for staff, new tracking mechanisms, and with the creation of sustainable partnerships with community organizations.

For More Information:

If you would like more information about the upstream work happening in our community please contact Ayesha Cammaerts at [email protected].