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Asthma Health Outcomes Project

Overviews of Surveyed Asthma ProgramsSeptember 2005

Domestic Programs: New York (cont’d)Back to Index

Asthma Care Coordination

Regional Community Asthma Network (RCAN) of the Finger Lakes

Rochester, NY

Cindy Trubisky, MH-Ed

(585) 442-4260         



The Regional Community Asthma Network of the Finger Lakes' Asthma Care Coordination program was implemented in 2000 to promote partnerships to reduce the social, medical and economic impact of asthma on children (5-14 years) in the Finger Lakes Region. Program goals include decreasing school absenteeism, emergency room visits, and hospital admissions; providing a forum for communication and collaboration for stakeholders in the asthma community to share and disseminate information; promoting professional and general public awareness and educational programs; developing a surveillance and data collection plan for an accurate assessment of asthma; and acting as a catalyst for change to facilitate improvement in asthma care and management.

The main components of the program is telephonic asthma care coordination and home visits. Once a child is referred to the program a nurse contacts the family for assessment. Four to six phone calls are made to educate the child and family and one last phone call is made for follow-up. Educational topics include triggers, medications, and the importance of seeing a primary care provider regularly. If a family is found to be in great need (poor control of asthma, have little resources or many triggers in the home, etc.) the family is referred to the environmental component of the program for a home visit and trigger assessment. There are approximately two home visits where the nurse conducts and assessment for triggers in the home. More education is provided and demonstrations are given to teach the family how to clean and mitigate triggers in the home. Follow-up phone calls are made to these families six to eight weeks after the home visits.

The program had a positive impact on the following health outcomes: hospital utilization, emergency department visits, school absences, quality of life for children, medication use, change in clinical actions, self-management skills, and use of an asthma action plan.

Program success is attributed to the nurses' dedication to the target population, and continued funding.

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