1. Integrating Asthma Control: A Tale of Entropy and Energy Jim Krieger, MD, MPH Public Health: Seattle & King County University of Washington King County Asthma Forum CDC 2002 National Asthma Conf

2. Introduction

3. The second law of thermodynamics Second Law of Thermodynamics: In the system of every spontaneous process there is an increase in entropy. Energy of all kinds in our material world disperses or dissipates if it is not hindered from doing so. Adding energy to the system blocks the increase in entropy. The Second Law applied to asthma control: Integration is the energy that blocks the tendency for entropy to increase in community asthma control efforts.

4. Concepts of integration Service coordination Filling gaps in services Linking service providers through cross-referrals Linking clients to providers Cross-institutional and multi-disciplinary collaboration Developing a shared vision Sharing asthma control resources Joining in program implementation, policy development and advocacy Linking people affected by asthma with institutions

5. Who is integrating? Community residents and families affected by asthma Health providers and institutions Schools Childcare providers Public Health agencies Parks and Recreation departments Health plans Public Housing agencies and private landlords Voluntary organizations (ALA, AAFA) Other CBOs and faith institutions Pharmacies and drug companies Academia

6. Concepts of integration: F amilies Consistent information Education provided in context of existing community programs and ethnic associations Communication across service providers Coordination between schools and health providers Being involved “Nurses, doctors, and parents [need to connect]. We all want to be involved and we want to know what’s going on with our kids. ”

7. Concepts of integration: Health providers Linkage of clinical care to community resources (public health nurses, community health workers) Common approach to asthma education and management Standardized documentation of asthma care

8. Concepts of integration: Health providers And the biggest problem I think we have is as primary care providers [is] we don’t necessarily know about when kids go to the Emergency Rooms. We usually get their hospitalizations, but not always. And if they have medication refills, if they don’t come into [our clinic] to get their refills we never know where they’re refilling those meds at.... And then to be able to share all that information with schools and childcare. And I then [the patients] that had...multiple households and multiple care providers, including extended family members, schools, childcare facilities. And having some sort of coordinated plan so that people understand all the issues of environmental controls as well as medication administration and verification of when kids are in trouble is my biggest challenge.

9. Concepts of integration: Health plans/insurers Case management to reduce utilization Uniformity in asthma management by contracted providers

10. Concepts of integration: Schools and school nurses Better communication with parents of children with asthma Coordination with public health on indoor environmental issues Standards of care across providers And so then you’re looking at a wide range of practitioners in terms of PAs and Nurse Practitioners and MDs, pediatricians, and all kinds of things. So I think that there’s kind of a full gamut between the kind of caring health professionals. And I think that, you know, having some kind of standards of care.

11. Concepts of integration: Childcare providers “For us, to have the information the doctor gave to the parents. Because when they come in with a nebulizer, it’s like “I’m told to give it three times a day,” or whatever the parent says... So, yeah, if we could actually get a copy from the doctor that prescribed it at that time.”

12. Concepts of integration: Public Health Community Asthma Control Plan Information sharing and cross- referrals among providers Consistency in asthma education and management Care coordination Data integration Cross-divisional integration

13. Concepts of integration: Public Health Nurse “I work primarily in schools, so I deal a lot with the school side of the issue, getting a management plan to the schools. And then coordinating -- I mean, communication is always, in case coordination, the biggest issue I work with -- coordinating care between physician, school, and family and incorporating all the elements that everybody else is doing.” “To really coordinate with the hospitals, the providers, and the ERs and do a really intense outreach with the clients and coordinate. You know, a team effort.”

14. Concepts of integration: Community Health Worker “Make sure that parents or the caregivers [is] knowledgeable....there’s got a lot of communication---school, parents, daycare. So everybody’s on the same page. And lots of coordination!” [Laughs slightly.]

15. Barriers to integration Barriers to integration can appear insurmountable! Berlin, 1961

16. Barriers to integration: Silos Silos Doing it your way Proliferation of action plans Development of disease management systems by health plans independently of providers Reluctance of providers and CBOs to change current practices to conform with standardized guidelines High value on organizational autonomy

17. Barriers to integration: Turf and control Securing resources and gaining recognition for one’s own organization Historical disagreements between organizations Personalities Proprietary ownership of resources and data

18. Barriers to integration: Clash of cultures Stakeholders from diverse cultures with differing perspectives on how to get things done Tension between “evidence based” and “experiential” knowledge

19. Barriers to integration: Clash of cultures “Comprehensive planning” vs. “action now” Process/relational vs. Task/outcome orientations

20. Barriers to integration: External forces Cost-containment and market competition for health plans and large institutions Productivity demands for health providers Test scores for schools

21. Barriers to integration: External forces Focus on revenue generation for non-profits Competing priorities for parents and children Constantly changing health care, political and business environments

22. Barriers to integration: Lack of resources and time Communication and coordination are time-consuming Staff not available to take on new roles Leadership not available to provide direction Organizations each have own timeline and priorities Local and state government budget woes and pressures to generate revenues

23. Overcoming barriers: Vague but true generalities Fight entropy by adding energy Keep your energy concentrated

24. Overcoming barriers: Vague but true generalities Use a coalition approach Articulate a clear and common vision Develop leadership that effectively promotes integration Balance task and process Model and support collaboration Use existing expertise to fill gaps Pool resources Share and equitably distribute opportunities for resources and recognition

25. Overcoming barriers: Vague but true generalities Build relationships Value respectful communication Step out of one’s traditional perspective and question one’s long-held beliefs Encourage participation by all parties Take simpler and smaller steps rather than do it all at once Praise altruism, but also recognize the power of self-interest

26. Overcoming barriers: Integrating care for individuals Community Health Workers Link families with schools, childcare, health providers, public housing Advocate for families for accessibility and consistency of services Care Coordinators Facilitate access to services Coordinate services across service providers Back-up CHWs Individual Asthma Action Plans

27. Overcoming barriers: Integration across organizations Community Asthma Action Plan Provides the blueprint Developed in a participatory, collaborative process Defines roles Multiple forums to foster integration Coalitions as the overarching roof Cross-project coordination groups Learning collaboratives for clinics Joint proposals and projects Conferences and community meetings Intra-organizational coordinating groups

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29. Overcoming barriers: Integration across organizations Inter-organizational linkages Schools  health providers, public health Health plans  community resources, health providers Hospitals and EDs  community resources, health providers Clinics  schools, childcare, community resources, hospitals and EDs, public housing Public Health  clinics, public housing, schools, childcare, hospitals and EDs, CBOs CBOs  clinics, childcare, public housing, other CBOs

30. Overcoming barriers: Integration across organizations

31. Inter-organizational cross- referral mechanisms Common tools, guidelines and messaging Single asthma action plan Shared educational resources and programs Consistent asthma control protocols Consistent key asthma messages

32. Overcoming barriers: Engaging diverse stakeholders Community residents Neighborhood Asthma Committees Focus groups and key informant interviews Educational events CBOs and agencies Community Outreach Committee Technical and grant-writing assistance Assistance with increasing agency reach and access to clients Direct service providers Virtual Clinical Committee: works by e-mail TA and resources for data and quality improvement

33. To conclude: Integration is a powerful tool to extend current resources and develop new ones. Integration doesn’t come easily but there are effective strategies to help get there. Paths to integration will vary by community and must fit the local landscape.