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Community-Based Asthma Initiative


Patients and their families may not always understand how asthma affects their bodies or how to best treat their symptoms. Regular visits to the Primary Care Provider (PCP), proper use of medicines, and education for patients and families improve the health and lifestyle of children with asthma. The Community-Based Asthma Initiative addresses these three factors by:

  1. Monitoring patients more closely with regular office visits
  2. Treating symptoms earlier by teaching patients and families how to correctly use their medicines and avoid triggers such as cigarette smoke
  3. Engaging patients and their families in their daily care


We arranged for a team of Care Coordinators to work with physician practices to help manage the care of children with asthma. They reached out to patients and families, provided guidance and education, helped coordinate their care, and ensured the children were able to get to appointments with their PCP.


To improve pediatric asthma care in our community


How did this initiative improve patient care?

  1. The average number of visits to a Primary Care Provider (PCP) increased by nearly three visits per patient per year. This suggests better partnering between patients and families and their primary care team.
  2. The number of prescriptions for “rescue” medicines, such as albuterol, decreased by almost 4 per year. This suggests that patients’ symptoms are better controlled.
  3. The average Asthma Control Test (ACT) score improved by about 2.5 points per patient. A patient with an ACT score of 19 or above is considered to have her/his symptoms “under control.” Our sample of patients had an average score of nearly 19 after rolling out the Community-Based Asthma Initiative.