SummaryThe Charlotte-Mecklenburg School District developed a series of policies designed to mitigate the impact of asthma on students by ensuring the creation of an asthma-friendly environment in the schools. The district wellness policy requires schools to create a school health team and offer training for school teams with a special focus on asthma; to comply with district-related policies in each building, including a ban on smoking and policies related to building management and pest control; and to designate school-based “first responders” for students experiencing asthma-related exacerbations. The school district also supported schools in putting in place various programs designed to meet the overall goals of asthma management, including active identification of students with asthma, monitoring students with asthma using an electronic database; providing case management of high-risk students with asthma; educating staff, students, parents, and the community; collaborating with other school departments (e.g. coordinated school health, health education, physical education, counseling/social work); and partnering with organizations that share a common mission related to asthma (e.g., emergency departments). While some aspects of the initiative have not been formally evaluated, the case management program for a subset of students has served as a catalyst for the provision of preventive services to prevent exacerbations, which in turn has led to improvements in health, quality of life, academic performance, and behavior, and less absenteeism.Suggestive: The evidence consists of trends in absences, behavior, academic performance, and self-reported health and quality of life in case-managed students over two semesters of an academic year, along with post-implementation data on the proportion of case-managed students receiving or having access to various services to prevent asthma exacerbation.
Developing OrganizationsCharlotte-Mecklenburg School District; Mecklenberg County (NC) Health Department
Date First Implemented2003
Age > Adolescent (13-18 years); Child (6-12 years); Vulnerable Populations > Children; Age > Preschooler (2-5 years); Vulnerable Populations > Urban populations
Problem AddressedApproximately 10 percent of students in a typical classroom suffer from asthma, which can negatively affect both their health and academic performance.1 As a location where children spend a large amount of time, schools represent a largely untapped opportunity to reduce the impact of asthma through coordinated policies and programs.
- A common condition: Approximately 9 million children in the United States have been diagnosed with asthma,2 and, in 2011, 23.0 percent of U.S. students in grades 9 through 12 reported that they had been told by a doctor or nurse that they had asthma.3 In the typical class of 30 students, approximately 10 percent (3 children) have asthma.1 The Charlotte-Mecklenburg school district is no exception; more than 10 percent of students (roughly 14,000 out of 132,000) have been identified as experiencing this condition.
- Negative consequences for health, academic performance: Asthma is the third leading cause of hospitalizations in children; low-income, inner-city, and minority children disproportionately experience emergency department (ED) visits, hospitalizations, and deaths due to asthma.1 Students with asthma often miss school, with approximately 13 million school days missed each year due to the condition.2 In Charlotte-Mecklenburg Schools, students with asthma miss an average of 4 days more per year than their peers without asthma.
- Largely unrealized potential of schools to minimize impact: Children spend many hours in school, making it a unique, important setting for policies and programs designed to minimize the impact of asthma on students. For example, asthma education can potentially be incorporated into lessons, and members of the school staff are often in a good position to monitor and help students manage asthma symptoms.1,4 Yet, relatively few schools or school systems play such a role.
Description of the Innovative Activity
The Charlotte-Mecklenburg School District developed a series of policies designed to mitigate the impact of asthma on students by ensuring the creation of an asthma-friendly environment in the schools. The policies require schools to create school health teams and provide training and materials with a special focus on asthma; to develop building-related procedures to comply with district policies, including a ban on smoking and policies related to building management and pest control; and to designate school-based “first responders” for students experiencing asthma-related exacerbations. The school district also supported schools in putting in place various programs designed to meet the overall goals of the asthma management program, including active identification of students with asthma; monitoring students with asthma using an electronic database; providing case management of high-risk students with asthma; educating staff, students, parents, and the community; collaborating with other school departments (e.g., health education, physical education, counseling/social work); and partnering with organizations that share a common mission related to asthma. More details on these policies and activities are provided below.
- School district policies: The school district has adopted various policies to promote an asthma-friendly environment in its schools, as outlined below:
- Mandatory wellness policy with asthma component: The district’s mandated wellness policy includes an asthma component and annual wellness training for all staff. As part of the policy, each school designates a school health team to evaluate school health- and wellness-related issues and develop action plans each year. These plans include student, staff, and community activities related to asthma.
- No smoking and no bus idling: To minimize environmental triggers, the district prohibits smoking on all (owned or leased) school property and requires bus drivers to turn off the engines if waiting for students for more than 5 minutes.
- Building services policies: The district has adopted building services policies to address environmental issues. This includes a timeframe of 24 hours or less for maintenance personnel to respond to any staff reports of health issues, including environmental triggers for asthma. It must also identify maintenance and custodial practices that promote a safer environment, such as use of environmentally friendly cleaning materials and high-efficiency particulate accumulator vacuums; regular maintenance of heating, ventilation and air conditioning systems; regular monitoring of oxygen, carbon dioxide, and general air quality; and appropriate pest control procedures.
- Monthly building inspections: District-based property managers inspect each school building monthly for condensation, mold, pests, and other asthma triggers.
- Designation and training of emergency “first responders”: School principals must select at least two first responders to be trained to manage emergency medical situations, including asthma exacerbations. First responders might be an assistant principal, a physical education teacher, a health teacher, or someone else comfortable with medical emergencies based on personal experience. Training sessions teach designated responders how to perform cardiopulmonary resuscitation, administer first aid, and use a defibrillator, and also provides education on the potential emergency medical needs of every student in the school with a high-risk health condition (including asthma). Whenever an emergency occurs, school staff immediately notify the school nurse and a first responder.
- Self-carry medication policy: The school district’s medication policy specifies that students who are capable, safe, and responsible may be authorized by a physician to carry medications such as asthma inhalers to school. The physician, a parent, the student, and the school nurse must all agree that the child can safely and reliably carry a medication.
- Programs to address and implement school policies: Charlotte-Mecklenburg Schools worked collaboratively with the Mecklenburg County Health Department and developed a School Health Services Manual that guides policy and practices. The schools have initiated a number of programs and activities in response to the districtwide policies, as outlined below.
- School nurse monitoring through database: School nurses use an electronic database to monitor all students with asthma. As outlined below, this process involves two steps—identifying students with asthma and monitoring them on an ongoing basis.
- Identifying students with asthma: School nurses identify most students with asthma by reviewing health cards completed annually by parents or by parent/guardian reports throughout the year. They become aware of others through teachers who provide the names of students with asthma. Others are identified during examinations of incoming kindergartners conducted at the school or when they present to the school nurse with wheezing symptoms. Since not all schools have fully designated nurses, good communication between staff and nurses is important.
- Ongoing monitoring through database: Whenever the nurse learns of a new asthma diagnosis, he or she enters the information on the student into an electronic database. By October 1 of each school year, school nurses review and document asthma management data on all students with asthma in their schools. Additionally, the nurse meets with each high-need student with asthma in the database to evaluate his or her condition and to update the information accordingly. The nurse meets with students and updates the database throughout the year, with a final update entered around May 1. The database provides absence data from the previous school year so that the nurse can prioritize which students to monitor most carefully (e.g., prior-year absences guide decisions on who to monitor most closely at the beginning of the year). The database also tracks information on triggers; symptoms; asthma-control test scores; peak flow meter readings; administration of influenza vaccinations; use of medications and spacers (a tube-like device attached to an inhaler to facilitate its use); development of an asthma action plan (see below); authorization to self-carry medication; and other asthma indicators, such as smoking in the home.
- Case management for at-risk students: Students who struggle with behavior, grades, absenteeism, quality of school participation, or general health as a result of their asthma are eligible for case management from a school nurse, as outlined below. School nurses are Mecklenburg County Health Department public health nurses who are contracted by the school district to provide services to students in the school setting.
- Case management services: The nurse assesses the student’s health and his/her ability to manage in school and then provides care and/or arranges for interventions as appropriate, often in collaboration with parents, physicians, and/or teachers. The nurse sees the student at least once a month (more often if needed) to reassess his or her health and the effectiveness of any interventions. The nurse performs an end-of-year assessment of progress toward defined goals; indicators include behavior, attendance, grades, quality of school life (e.g., participation in sports and activities, relationships with others), and health.
- Asthma action plan: The nurse collaborates with hospital case managers, physicians, parents/guardians, and the student to secure the development of an asthma action plan—a one-page form that lists the student’s asthma triggers, symptoms, medication use, peak flow readings, and parent/physician contact information. The plan is organized according to the American Lung Association’s classification of appropriate response to an asthma episode (i.e., green zone to indicate asthma under good control; yellow zone to indicate mild symptoms; and red zone to indicate an asthma emergency). In 2009, the district collaborated with the local health department, hospital system, and local asthma coalition to develop a new asthma action plan based on the newest asthma guidelines. The nurse, student, a parent, and the student’s physician/provider sign the form. The back of the plan has an authorization form to allow the student to carry medication in school.
- Annual asthma education for staff: At the beginning of each school year, the school nurse trains all school staff on various topics, including asthma. The asthma-related education includes the following:
- Teachers: Each year, teachers receive written information on asthma and watch a 10-minute video developed by the Western New York Asthma Coalition called “Asthma 911.” Training sessions also encourage teachers to know which students have asthma and to request a copy of the student’s asthma action plan, learn about the student’s triggers, and notify the physical education teacher of students with exercise-induced asthma. Training emphasizes the importance of keeping classrooms free of clutter; avoiding use of scented cleaners and air deodorizers; not keeping furry or feathered animals in the classroom; not blocking air vents and windows; using only nontoxic cleaning supplies; and promptly alerting maintenance staff about any leaks, condensation, or mold.
- School nurses: School nurses receive education from county health department asthma nurses via a 3-hour module incorporated into new employee orientation. The module includes information about asthma treatment, relevant school district policies and procedures, and asthma-related resources in the community. School nurses also participate in a districtwide annual school health skills fair that provides education on a variety of topics, including asthma technologies and medications.
- After-school enrichment staff: Each quarter, members of the after-school enrichment staff attend a 2-hour training program that uses materials from the American Lung Association’s “Asthma 101” program.
- Bus drivers: Bus drivers receive internet-based training using a module developed by the school district on how to respond to an asthma attack.
- Asthma awareness education for students, parents, and the community: As detailed below, education modules for students, parents, and the community focus on building asthma awareness and providing education about symptoms, triggers, and control.
- Students: Students with asthma may receive asthma education modules that vary by grade level; programs include Open Airways (grades 3-5) and Kickin’ Asthma (grades 6-10). These programs provide asthma education in a fun, interactive series of classes that empower students to gain lifelong asthma management skills. To heighten asthma awareness for all students, Asthma on Wheels (grades 4-6) and High School Asthma Awareness (grade 9) programs are available. These programs allow teachers to integrate asthma-related topics into the standard course of study and promote asthma-friendly classrooms. Students learn to define asthma and asthma triggers, list ways to control asthma, and identify ways to help a friend with the disease.
- Parents: Parents can receive free asthma education through “Parent University” classes conducted by the Mecklenburg County Asthma Coalition. School nurses may also offer education classes to parents in their schools.
- Community education: The school district collaborated with the Mecklenburg County Asthma Coalition to plan and implement a Community Asthma Forum on Current Trends in Asthma, held annually in May. In 2011, the forum included an expert panel (a community pediatrician, allergist, pulmonologist, school health specialist, and psychologist) that discussed asthma-related topics and answered questions, along with a video featuring local students with asthma. Nearly 150 community members attended.
- Partnerships with other organizations: The school district maintains a number of partnerships that support its efforts. For example, the University of North Carolina Charlotte Institute of Social Capital and the Dickson Institute (Carolinas Health Care System) analyze the data in the electronic tracking system at the end of each school year to evaluate interventions and inform the development of new processes. In another partnership, Levine Children’s Hospital and Community Care Partners of Greater Mecklenburg (the local Medicaid provider) send a report to school nurses whenever a high-need student is treated in the ED or hospitalized for asthma. The school district also partners with community physicians, pulmonologists, allergists, and respiratory care specialists, who provide continuing education workshops for school nurses and staff and serve as a clinical resource.
Langenfeld NA, Mast DK, Rasberry CN, et al. Strategies for identifying students in need of school-based asthma services: challenges and questions that emerged from a rapid evaluation of a school-based asthma program. J Asthma Allergy Educators. 2010 June;1(3):109-116.
Schlueter DF, Rasberry C, Buckley R, et al. Secondhand tobacco smoke exposure among school-aged youth in school based asthma management programs: a mixed method analysis. J Asthma Allergy Educators. 2011 August;2(4):173-180.
Langenfeld NA, Bonaiuto MM, Edmonds EO. Garnering administrative support for school-based asthma education programs. J Sch Health. 2006 August;76(6):250-254. [PubMed]
Bonaiuto MM. School nurse case management: achieving educational and health outcomes. J Sch Nurs. 2007 August;23(4):202-209. [PubMed]
US Environmental Protection Agency. Health and Achievement: Managing Asthma in the School Environment. Case Study: Charlotte-Mecklenburg Schools. December 7, 2011. Available at: http://www.epa.gov/iaq/schools/managingasthma.html.
US Environmental Protection Agency. IAQ Tools For Schools. Develop Your Program: Key Drivers: Case Studies. Charlotte-Mecklenburg Schools: Organizing to Institutionalize Proactive IAQ Management. Available at: http://www.epa.gov/iaq/schools/casestudies.html#charlotte.
Centers for Disease Control and Prevention. Adolescent and School Health. Charlotte-Mecklenburg, North Carolina. March 1, 2011. Available at: http://www.cdc.gov/healthyyouth/states/locals/nc-charlotte-mecklenburg.htm#1.
Charlotte-Mecklenburg School District Web sites:
Environmental stewardship policy available at: http://www.cms.k12.nc.us/cmsdepartments/construction/buildingservices/EMS/Pages/default.aspx.
Controlling asthma triggers available at:http://www.cms.k12.nc.us/cmsdepartments/construction/buildingservices/EMS/Pages/Asthma.aspx.
Coordinated School Health Program available at: http://www.cms.k12.nc.us/cmsdepartments/csh/Pages/default.aspx.
Asthma Education Program available at: http://www.cms.k12.nc.us/cmsdepartments/csh/AsthmaEdu/Pages/default.aspx.
Contact the InnovatorNancy A. Langenfeld, MS, RN
Coordinated School Health Specialist
Charlotte Mecklenburg Schools
700 E. Stonewall St, Suite 708
Charlotte, NC 28202
Maria Bonaiuto, RN, MSN, NCSN
Director of School Health
Mecklenburg County Health Department
5727 Westpark Drive Suite 200
Charlotte, NC 28217
Innovator DisclosuresMs. Langenfeld and Ms. Bonaiuto reported no financial interests or business/professional affiliations relevant to the work described in this profile.
While some aspects of the initiative have not been formally evaluated, the case management program has served as a catalyst for the provision of many preventive services to prevent asthma exacerbations, which in turn have led to improvements in health, quality of life, academic performance, and behavior, and less absenteeism.
Suggestive: The evidence consists of trends in absences, behavior, academic performance, and self-reported health and quality of life in case-managed students over two semesters of an academic year, along with post-implementation data on the proportion of case-managed students receiving or having access to various services to prevent asthma exacerbation.
- Catalyst for provision of preventive services: During the 2010-2011 school year, 484 children received case management services, which have been a catalyst for interventions designed to prevent asthma exacerbations. For example, 90 percent of case-managed students have an asthma action plan in place and 95 percent have quick relief medications at school. In addition, 53 percent have spacers, and 83 percent have had an asthma control test administered.
- Better health and quality of life: Overall, 95 percent of students receiving case management reported an overall improvement in health, while 99 percent reported improvements in their quality of life.
- Better academic performance and behavior: Based on teacher reports, just over one-half (53.3 percent) of case-managed students who needed to improve their academic performance did so over the course of the 2009-2010 school year. (Overall, 51 percent of case-managed students were identified as needing to improve their academic performance; the rest did not.) Based on the number of suspensions and other disciplinary actions over the two semesters, two-thirds of case-managed students who needed to improve their behavior at school did so. (Overall, 37.5 percent of case-managed students were identified as needing to improve behavior; the rest did not.)
- Less absenteeism: Overall, 35 percent of case-managed students (of those needing attendance improvement) improved their attendance between the fall and spring semesters of the 2009-2010 school year. Those classified as “high need” experienced a statistically significant decline in the average number of days absent (from 6.82 to 5.05 days).
- Increase in case managed students: Between the 2009-2010 and 2011-2012 school years, the percentage of hospitalized students with asthma who were case managed by school nurses increased by 39 percent. This positive trend demonstrates the growing number of high-need students with asthma who receive case management.
Context of the InnovationThe twenty-third largest school district in the nation, Charlotte-Mecklenburg School District operates 167 public schools that serve approximately 132,000 students, more than 14,000 of whom have asthma.4 The roots of this program go back to 1999, when the district began participating in Duke University’s International Study of Asthma and Allergies in Childhood (ISAAC). This study quantified the large number of children with asthma and also triggered interest among school district leaders in mitigating the impact of asthma. ISAAC also prompted the US Centers for Disease Control and Prevention (CDC) to begin funding school-based asthma initiatives. In 2002, Charlotte-Mecklenburg Schools collaborated with the Mecklenburg County Health Department/School Health and applied for and was granted a CDC cooperative agreement to develop and implement school-based asthma policies and programs using a formal strategy called the “coordinated school health approach.” This approach consists of eight components—health services, health education, physical education, nutrition services, counseling, staff wellness, family/community involvement, and a healthy school environment. Together, Charlotte-Mecklenburg Schools and the Mecklenburg County Health Department/School Health partnered to become the Charlotte-Mecklenburg Schools Asthma Education Program and designed the initiative.
Planning and Development Process
Selected steps included the following:
- Selecting schools to pilot test program: The Charlotte-Mecklenburg Schools Asthma Program staff selected 15 schools to participate in a pilot test based on student and school-level demographic data and asthma statistics provided by school nurses.
- Gaining support of principals: A representative of the school district and a health department asthma nurse presented information to the principals of the 15 selected schools about their school’s specific asthma profile and on the connection between asthma programs, school improvement, and student achievement. Presentations highlighted the relationship between asthma and measures for which the school district and individual schools must be accountable, such as student attendance, staff development, parent involvement, and maintaining a safe school environment.
- Creating asthma team: Each participating school formed an asthma team composed of a nurse, physical education teacher, counselor, nutritionist, teacher, parent of a child with asthma, and/or school administrator. These teams have since transitioned into broader “school health” teams; although they still focus on asthma, they now oversee other school health initiatives as well.
- Developing asthma activity plans: Each team conducted a needs assessment using the School Health Index and developed an action plan that included asthma activities for students, staff, and families based on a CDC resource known as “Strategies for Addressing Asthma within a Coordinated School Health Program” (see the Tools section for more information). The plans focused on incorporating staff and student education into the school day, training first responders, and adopting policies to ensure an asthma-friendly environment.
- Developing training programs: The school district identified existing training modules and developed other training programs internally.
- Meeting with key stakeholders and partners: School district representatives worked with different county departments (such as the transportation department, which oversees school bus drivers) and staff (such as physical education teachers) to develop staff-specific policies and programs in preparation for district-wide rollout of the program. They also met with representatives of various organizations—such as the local children’s hospital, parent-teacher associations, and the county asthma coalition—to discuss the problem and explore the potential for partnerships. They also invited national speakers to make presentations to different groups about asthma and its impact on students. One significant impetus that occurred early in the process was a forum involving school leadership (the superintendent, Board of Education members, district and school administrators, county/city government representatives, and school nurses) to hear and work with national speakers. This resulted in strong, ongoing national partnerships with Association of School Administrators (AASA), American School Health Association (ASHA), Environmental Protection Agency (EPA) Tools for Schools, National Association of School Nurses, and others.
- Rolling out across entire district: Based on the success of the pilot test, the program has been expanded districtwide. As part of this rollout process, the school district developed policies regarding the development of school health teams, asthma training, and asthma case management. They communicated these policies during school district meetings and through e-mails sent to all principals. This communication effort continues on an ongoing basis through reminder e-mails and policy briefs distributed throughout the year that highlight different components of the policies.
Resources Used and Skills Needed
- Staffing: The school district dedicates three full-time equivalent (FTE) staff to the program—two asthma management nurses and one health educator. Other program activities are integrated into the responsibilities of a coordinated school health specialist and existing staff of the school district, partner organizations, and schools. School nurses spend an estimated 15 to 25 percent of their time working with students with asthma.
- Costs: Program costs total approximately $220,000 annually.
Funding SourcesCenter for Disease Control
The CDC has funded the program since its inception in 2003 through an initial 5-year cooperative agreement and a subsequent 4.5-year cooperative agreement. Several smaller grants provided limited funding for asthma programs and collaboration with the Mecklenburg County Asthma Coalition. In October 2010, the school district started participating in an AHRQ study (“Comparative Effectiveness of Asthma Interventions within a Practice Based Research Network”) that provides funds to finance an electronic health record for school nurses, database development, and the activities of a full-time researcher to evaluate asthma care within Charlotte-Mecklenburg County. These funds are earmarked for research and not used for program development and operations.
Tools and Other Resources“Strategies for Addressing Asthma within a Coordinated School Health Program” is available at: www.cdc.gov/HealthyYouth/asthma/pdf/strategies.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software .).
The following tools are available from the innovator:
- Asthma Case Management Check-Off List Guide
- Asthma Action Plan/Medication Authorization Form
- School Asthma Checklist (for parents)
Getting Started with This Innovation
- Start small: Pilot test the program in a few schools, as early successes will facilitate program expansion at a later date.
- Measure outcomes: Measure outcomes to inform the process and make program adjustments. Program success and development is an ongoing process. This is especially important when building a program and communicating the effectiveness of interventions to stakeholders. Establishing effective data collection tools and baseline data results in informed and target decision making. It also helps answer the question for school leaders: “Why should we implement this program in our schools?”
- Garner administrative support: Use district and individual school profile data to open communication on the need for asthma policies, education, and programs in the schools. Link specific data to attendance and student performance (number of students with asthma; absences; health office visits, time out of class, etc.) and to district and/or principal goals.
- Recognize need to make an investment: Developing effective districtwide asthma policies and programs requires a meaningful investment, including the funding to support dedicated staff (at least one FTE) and the development of education and training materials. Program developers may be able to use data on the program’s potential impact to solicit grant funding.
- Provide school-specific data to principals: Principals will be more likely to support the program if they see how many students in their school have asthma and the impact the disease has on absenteeism and the number of school nurse visits and parent calls.
- Be flexible: Teachers and administrators may be concerned about fitting asthma education into the school day. To address these concerns, develop programs that easily integrate into existing events and programs, thus ensuring they will be minimally disruptive. For example, staff development activities can be provided during regularly scheduled meetings, and student education can be folded into existing lessons or provided during physical education classes.
- Identify community partners: Community-based organizations with similar missions can serve as valuable partners by assisting with policy and program development and implementation, and providing continuing asthma education for school staff and school nurses. Potential partners include the local asthma coalition, hospitals, parent groups, the county health department, and others. In addition, groups such as the American Lung Association and the National Association of School Nurses can offer expertise and evidence-based programs for adoption.
Sustaining This Innovation
- Introduce formal asthma policies as program expands: Programs and tools are not enough to ensure the program’s effectiveness over time, particularly as it rolls out over a broad geographic area (such as an entire school district). Rather, formal policies must underlie the initiative to ensure consistent adoption and adherence. School district policies should specify not only the content and frequency of training programs, but also detailed strategies and activities that support the creation and maintenance of an asthma-friendly environment in schools.
- Integrate education, programs, and practices into existing systems: Asthma programs should be integrated into the existing health curriculum, school health teams, and programs involving staff development hours for credit.
- Communicate frequently: Communicate with schools and school-based staff on an ongoing basis to ensure that asthma policies remain top-of-mind and that resources to assist in operationalizing them remain readily available.
Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance—United States, 2011. Morbidity and Mortality Weekly Report. 8 June 2011;61(4):1-168. Available at: http://www.cdc.gov/mmwr/pdf/ss/ss6104.pdf
4 Langenfeld NA, Mast DK, Rasberry CN, et al. Strategies for identifying students in need of school-based asthma services: Challenges and questions that emerged from a rapid evaluation of a school-based asthma program. J Asthma Allergy Educators. 2010 June:109-116.
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Original publication: August 29, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: October 03, 2012.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.