The Breathmobile^™Program: Structure, Implementation, and Evolution of a Large-Scale, Urban, Pediatric Asthma Disease Management Program

Abstract

Despite more than a decade of education and research-oriented intervention programs, inner city children with asthma continue to engage in episodic "rescue" patterns of healthcare and experience a disproportionate level of morbidity. The aim of this study was to establish and evaluate a sustainable community-wide pediatric asthma disease management program designed to shift inner city children in Los Angeles from acute episodic care to regular preventive care in accordance with national standards. In 1995 the Southern California Chapter of the Asthma and Allergy Foundation of America (AAFA), the Los Angeles County Department of Health Services (LAC DHS), and the Los Angeles Unified School District (LAUSD) established an agreement to initiate and sustain the Breathmobile Program. This program includes automated case identification, mobile school-based clinics, and highly structured clinical encounters supported by an advanced information technology solution. Interdisciplinary teams of asthma care specialists provide regular and ongoing care to children at school and county clinic sites over a wide geographic area of urban Los Angeles. Each team operates in a specially equipped mobile clinic (Breathmobile), efficiently moving a structured healthcare process to school and county clinic sites with large numbers of children. Demographic, clinical, and participation data is tracked carefully in an electronic medical record system. Program operations, clinical oversight, and patient tracking are centralized at a care coordination center. Clinical operations and methods have been replicated in fixed specialty clinic sites at the Los Angeles County + University of Southern California Medical Center. Clinical and process measures are regularly evaluated to assure quality, plan iterative improvement, and support evidence-based care. Four Breathmobiles deliver ongoing care at more than 90 school sites. The program has engaged over five thousand patients and their families in a continuity care model that has demonstrated efficacy over usual episodic care. More than 90% of patients in all asthma severity categories achieved clinical control of asthma with significant reductions in inpatient (IP) and emergency department (ED) use. On February 14, 2002, the program became the first program in the United States to receive the award of disease-specific care certification by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Proper design and resource allocation can sustain a school-based community-wide pediatric asthma disease management program and shift a population of inner city children from acute episodic care to routine preventive care in accordance with national standards. An evidence-based approach to evaluating and maintaining quality, coupled with stratified care delivery, can assure the efficient use of safety net healthcare resources.

Achieving and maintaining asthma control in inner-city children

“…10,[19][20][21][22][23][24][25][26][27] Implementation of the Breathmobile program sought to remove barriers to care, providing preventive specialty-based asthma care to this high-risk population. 11,13 Participation in this program is associated with reductions in asthma-related morbidities, evidenced by 2/3 reduction in the percentage of patients reporting ED visits and over 3/4 reduction in hospitalizations and > _5 missed school days per year. The current study provides significant data about real-world patterns of asthma control in predominantly underserved populations.…”

“…This study evaluated asthma control for patients enrolled in similarly structured mobile asthma programs previously described 13 September 26, 2006), and San Bernardino County, Calif (Arrowhead Regional Medical Center Breathmobile Program, June 18, 2007). Hereafter, sites are referred to by geographic region.…”

“…11,12 Among these is the Breathmobile program, initiated in Los Angeles in 1995. 13 This school-based disease management program uses fully equipped mobile clinics staffed by specialty trained asthma providers and integrates strategies for case identification, community outreach, continuity of care, structured healthcare encounters, and patient tracking. This model serves to reduce barriers to delivering effective asthma care.…”

“…This model serves to reduce barriers to delivering effective asthma care. 11,13,14 Similarly structured programs now operate in multiple US cities and collaboratively offer a novel opportunity to analyze the efficacy of regular, guidelines-based comprehensive care 1,15,16 to achieve and maintain asthma control in a large, heterogeneous, realworld pediatric population.…”

Inner-city asthma: Control can be achieved!

“…15 This outreach program, known as the Breathmobile program, started very simply, with a single mobile unit in the city of Los Angeles. However, over a short time, the program evolved into a more comprehensive and integrated pediatric asthma disease management program that now consists of several mobile units in 4 major cities in 4 states.…”