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Service Delivery Innovation Profile

Comprehensive Screening, Guideline-Based Treatment, and Self-Management Support Enhanced Access to Asthma Care, Reduced Hospitalizations and Costs

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The Urban Health Plan Asthma Relief Street program provides standardized, comprehensive asthma screening, guideline-based treatment,1 education, and self-management support at 12 health centers. The program also supports community-based organizations that serve low-income, at-risk populations in the area. The program increased the number of people diagnosed with and treated for asthma, reduced asthma hospitalizations among children, and generated significant cost savings.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation data on the number of asthma patients identified and treated by the organization and on asthma-related hospitalizations among area children, along with post-implementation comparisons of health care spending on adults and children with asthma.
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Developing Organizations

Urban Health Plan, Inc., Bronx NY
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Date First Implemented

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Patient Population

Vulnerable Populations > Impoverishedend pp

Problem Addressed

Asthma is a common disease, especially among children and inner-city poor people. Left undiagnosed and untreated (as often occurs with low-income individuals with asthma), the disease can lead to increased emergency department (ED) visits and hospitalizations, and in some cases to death.1-5
  • A common disease, especially among children and inner-city poor people: More than 22 million Americans have asthma; an estimated 6 million are children.1 The problem tends to be worse in inner-city areas.2,3 In New York City, one in eight adults report having received a diagnosis of asthma at some point in their life, with the Bronx having the highest overall rates. Low-income children face an especially high risk. Children between the ages of 4 and 5 years from low-income areas are more than twice as likely to get asthma than similar-age children residing in high-income areas.4
  • Heavy burden of asthma: EDs and hospitals often treat those experiencing asthma attacks, particularly low-income individuals who have no other source of care.5 In 2000, asthma-related inpatient admissions in New York cost more than $242 million, and an estimated 204 individuals died due to complications from the disease.4
  • Largely unrealized benefits of proactive identification and treatment: Many asthma-related complications and their associated costs can be avoided through proactive identification, monitoring, and treatment of the disease. But, many low-income individuals remain undiagnosed and/or lack access to ongoing monitoring and treatment.2,3

What They Did

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Description of the Innovative Activity

The Urban Health Plan Asthma Relief Street program provides comprehensive, standardized asthma management at 12 health centers, with every asthma patient being evaluated at every visit, regardless of his or her point of entry into the system. For those identified as having asthma, trained health care providers offer guideline-based treatment,1 education and self-management support, and follow up monitoring and care. The program also supports community-based organizations that serve low-income, at-risk populations in the area. Key components include the following:
  • Comprehensive screening: All patients visiting any health center site are automatically evaluated for asthma, with those already diagnosed with asthma being assessed at every primary care visit and those not previously diagnosed being screened twice per year. A medical assistant begins the evaluation process by using a standardized electronic management form to assess any history of asthma or any asthma-related symptoms experienced within the past 14 days. Children age 6 and older receive an exhale nitric oxide test. A physician evaluates the form and any test results as a part of the screening and intake process.
  • Guideline-based asthma treatment, with electronic record support: Primary care physicians who staff the health center site follow standardized asthma treatment protocols based on national guidelines.1 For those patients identified through the evaluation process as having asthma, physicians assess their condition and classify it as being intermittent, mild, moderate, or severe, with medications prescribed accordingly. Patients with asthma are seen by the physician at least every 3 months. To facilitate the provision of guideline-based treatment, physicians use standardized evaluation and treatment planning forms within the organization's electronic medical record (EMR) system. These forms serve as a decision-support tool that promotes adherence to the guidelines, with the system being updated to reflect changes in guidelines as evidence evolves. For example, after new guidelines recommended providing the Asthma Control Test at every asthma visit, the EMR was modified to remind physicians to fulfill this requirement.
  • Ongoing education and self-management support: Patients diagnosed with asthma see a health educator during each visit, regardless of whether the visit is for asthma treatment. (Every health center employs at least one health educator.) Health educators use an integrated approach to education and self-management support, as outlined below:
    • Asthma education: Health educators teach patients about asthma and how to identify its signs, symptoms, and triggers.
    • Development of asthma action plan: Health educators, patients, and providers jointly develop and thoroughly discuss an asthma action plan, which helps tailor treatment to individual needs. The action plan assists patients in knowing when and how often to take their medication, and how much medication to take when symptoms arise. The plan also guides patients as to when to go to the health center or an ED if symptoms do not improve.
    • Support for ongoing self-management: Health educators support patients in managing their illness by demonstrating use of asthma equipment (e.g., nebulizer compressors, inhalers, spacers, Diskus) and by providing tips, suggestions, and strategies for managing the disease and its symptoms. For example, health educators may give patients with persistent and/or uncontrolled asthma a watch with a preset alarm to help the patient remember to take his or her medications as prescribed.
    • Integrated support team: The Urban Health Plan works closely with allergists, pulmonologists, social services, and Healthy Nest (a pest management program) to provide integrated health care services. Pest management involves inspection, identification, and treatment of pests that contribute to allergen levels. Healthy Nest staff test the homes of patients referred to the organization for allergen levels, and then provide services to reduce allergen levels in the home as needed.
  • Postvisit patient followup, with support from registry: A registry captures data on all patients diagnosed with asthma and reminds providers as to the appropriate follow up regimen. For example, patients with severe asthma who receive a nebulizer treatment in the office receive a call within 48 hours. Those with mild to moderate asthma who had changes in their asthma action plan are scheduled to return within 2 weeks, whereas those with intermittent asthma return in 6 months. Providers routinely encourage patients experiencing out-of-control symptoms to come in without an appointment.
  • Ongoing tracking, reporting for quality improvement: The EMR system allows for ongoing monitoring of the quality of care being provided to asthma patients. The EMR also integrates the Asthma Control Test (ACT), which is completed each time an asthma patient visits their provider. Physicians receive monthly performance reports to stimulate quality improvement.
  • Community-based education and support: Urban Health Plan complements its work with patients by supporting the activities of community-based organizations that serve low-income populations at risk of asthma. For example, staff serve on multiple community boards in an advisory capacity on asthma-related issues, participate in community health fairs and other events, and provide asthma education in schools, daycare facilities, and other community-based organizations.

Context of the Innovation

A Federally Qualified Health Center, Urban Health Plan, Inc., serves more than 30,000 patients a year through 170,000 visits. The organization operates 12 health centers in the Bronx: 3 primary care sites, 5 primary care school-based health centers, 4 smaller health centers (including 2 that operate out of homeless shelters), a dental services clinic, and an adult care treatment health center focused on geriatric health. The asthma program began in 2001 as a performance improvement project prompted by the Health Resources and Services Administration, which encouraged all Federally Qualified Health Centers to participate in the Health Disparities Collaborative, sponsored by the Bureau of Primary Health Care. Having tried unsuccessfully to make changes on their own, Urban Health Plan leaders became interested in this opportunity to develop new ways to care for patients with asthma. The organization was one of 20 health centers selected to participate in the collaborative.

Did It Work?

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The program increased the number of people diagnosed with and treated for asthma, reduced asthma hospitalizations among children, and generated significant cost savings.
  • More people identified and treated: From 2001 to 2006, the number of asthma patients listed in the asthma registry increased from 2,100 to 6,414. In 2009, 22 percent of the 1,000 patients screened received a diagnosis of asthma; before this screening, none of these individuals knew they had asthma.
  • Fewer hospitalizations among children: From 1997 to 2004, asthma-related hospitalization rates among children fell by 67 percent in the program's service area.
  • Cost savings: An outside study comparing health plans showed that in 2006 to 2007, total per-person health care cost for adults with asthma covered by Urban Health Plan averaged 22 percent less than for other adult patients in the network. Comparable figures for children showed 39 percent lower costs.

Evidence Rating (What is this?)

Moderate: The evidence consists of pre- and post-implementation data on the number of asthma patients identified and treated by the organization and on asthma-related hospitalizations among area children, along with post-implementation comparisons of health care spending on adults and children with asthma.

How They Did It

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Planning and Development Process

Key steps in the planning and development process included the following:
  • Initial patient identification: Urban Health Plan began by identifying 135 patients with asthma being treated by the pediatrics department. Staff gathered baseline information for these patients and entered it into the patient registry.
  • Small-scale testing of changes: As part of the Health Disparities Collaborative, program leaders reviewed all components of the Chronic Care Model, which summarizes the basic elements for transforming the health care system to appropriately meet the needs of patients with chronic illnesses. Urban Health Plan began testing process changes, such as involving medical assistants in standardized screening and using health educators to improve patient self-management. Participation in the collaborative allowed rapid testing on small populations to see if the changes resulted in improvement.
  • Rollout and institutionalization of successful practices: The organization rolled out successful strategies and practices to other populations, patients, and sites. In addition, Urban Health Plan redirected resources to support institutionalization of the changes so that they could be sustained over time. For example, after the concept of health educators proved successful (using existing staff), the organization allocated funds to hire dedicated educators.
  • Infrastructure development: Urban Health Plan invested in infrastructure to support the program, such as a new electronic system that can track patient data and report on quality performance through production of user-friendly charts and graphs.
  • Development of community partnerships: Urban Health Plan leaders fostered strategic partnerships designed to integrate the organization's work with that of other agencies serving high-risk populations in the community.

Resources Used and Skills Needed

  • Staffing: Urban Health Plan employs 380 staff across its 12 clinics, including 71 medical providers. Staff involved in developing and rolling out this program across the clinics included senior leaders, physicians, health educators, medical assistants, and information technicians.
  • Costs: The organization's total annual operating budget is approximately $31 million; data on the operating costs related to this program are not available. Because these changes have been institutionalized, the program does not require a dedicated budget.

Tools and Other Resources

More information on the guidelines used by Urban Health Plan is available at

More information on the Chronic Care Model is available at

Adoption Considerations

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Getting Started with This Innovation

  • Gain support from senior leaders: This program cannot succeed without full support from senior leaders. At Urban Health Plan, these leaders attended every implementation team meeting and served as an integral part of the project team.
  • Build consensus among staff and physicians: Although staff generally believe they are doing the best they can, room for improvement always exists. Build consensus for change among staff and physicians by highlighting the gap between current care and best practices. Physician champions can be effective in conveying this message to their peers.
  • Push for transformative change: This program requires senior leaders and staff to carefully assess the current care process and be open to radically changing the way services are provided.
  • Develop team approach to care: The quality and comprehensiveness of care can be increased by use of a team approach. For example, dividing responsibilities for the standardized asthma screening between medical assistants and physicians helps to facilitate comprehensive care without placing an undue burden on doctors.

Sustaining This Innovation

  • Institutionalize changes: Changes endure only when integrated into an organization's formal policies and procedures. For example, the use of EMRs to standardize and update screening and treatment guidelines and forms allows Urban Health Plan staff to easily keep abreast of and incorporate new scientific evidence into the everyday practice of medicine.
  • Monitor performance and provide feedback: Collect data on an ongoing basis to monitor performance and provide feedback. Sharing user-friendly data and graphs that show performance over time during monthly meetings allows staff and physicians to see how their patients fare in comparison with those treated by other providers. These data can also be used to work with individual providers on performance issues.

Additional Considerations

This program has been recognized by the New York City Department of Health and also received the 2006 National Exemplary Award from the U.S. Environmental Protection Agency.

More Information

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Contact the Innovator

Paloma Hernandez, MPH, MA
President and CEO
Urban Health Plan, Inc.
1065 Southern Boulevard
Bronx, NY 10459
(718) 991-4833

Innovator Disclosures

Ms. Hernandez has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.


1 Expert Panel Report 3 (EPR-3). Guidelines for the Diagnosis and Management of Asthma – Summary Report 2007. U.S. Department of Health and Human Services, National Institutes of Health, National Health Lung and Blood Institute, NIH Pub No. 08-5846; October 2007.
2 National Institute of Allergy and Infectious Diseases (NIAID). Available at:
3 The Inner-City Asthma Intervention Web site. Centers for Disease Control and Prevention. Available at:
4 Garg R, Karpati A, Leighton J, et al. Asthma Facts, Second Edition. New York City Department of Health and Mental Hygiene; May 2003.
5 Akinbami LJ. The State of Childhood Asthma, United States, 1980-2005. U.S. Department of Health and Human Services, Advance Data from Vital and Health Statistics, No. 381; 2006. Available at: (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software External Web Site Policy.)
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Original publication: May 11, 2009.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: December 04, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: December 03, 2010.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.