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Asthma Health Outcomes Project

Overviews of Surveyed Asthma ProgramsSeptember 2005

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

Monroe Plan and ViaHealth Partnership for Improving Asthma Care for Children

Monroe Plan

Rochester, NY

Joseph A. Stankaitis, MD, MPH

(585) 256-8425         


The Monroe Plan and ViaHealth Partnership: Improving Asthma Care for Children program began in 2001 in Rochester, NY and is still ongoing.

The goal of the program is to improve the identification and diagnosis of children with asthma within the Monroe Plan-ViaHealth population, help patients and their families better manage their disease, and through outreach, coordinate their care in primary care, specialty, and school settings. Patients served are Monroe Plan managed care enrollees with ViaHealth primary care physicians in ViaHealth's three Community Health Center pediatric practices and three School Based Health Centers.

Upon enrollment in the program, each patient receives a formal clinical evaluation, including pulmonary function tests, allergy skin testing, and asthma education. An Outreach Worker makes home visits to conduct visual trigger assessments and provide asthma education. Meanwhile, a Care Coordinator works to communicate with the primary care provider and specialists as well as the outreach worker and family to ensure the patient receives appropriate medical care and services. All program activities are tailored to individual patient needs.  The program also includes a Clinical Quality Improvement component. Each practice has a quality team made up of MDs, RNs, and practice administrators that meets every other week and follows a formal CQI process to address clinical quality issues.

The ongoing evaluation on the program has shown a positive impact on several health outcomes over time and in comparison to patients within another local healthcare delivery system. In light of this success, the Monroe Plan is in the process of rolling the program out to all its sites throughout 13 counties in New York.

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