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Asthma Health Outcomes Project

Overviews of Surveyed Asthma ProgramsSeptember 2005

Domestic Programs: Massachusetts (cont'd) Back to Index

Asthma Chronic Care Team

Holyoke Health Center

Holyoke, MA

Sally Neuner, RN

(413) 420-2166         

sally.neuner@hhcinc.org

The Asthma Chronic Care Team of the Holyoke Health Center in Holoyoke, MA originated in 2001 as part of the Health Disparities Collaborative of the Bureau of Primary Health Care.

Patients with asthma of any age are referred to the program by their primary care provider upon diagnosis of asthma. At the clinic, a primary assessment is completed, a severity score is assigned, and the patient receives asthma education either on site or at home. Individual patient education is offered as needed as well as family groups and support sessions. Education is culturally and linguistically appropriate for the mainly low-income, Hispanic target population. Following the chronic care model, continuous quality improvement efforts are implemented to ensure all patients receive appropriate asthma treatment. A physician champion works to get the latest asthma treatment guidelines to all providers, experts provide quarterly trainings, and a decision support team creates documentation and systems to support care.

Ongoing program evaluation indicates a positive impact on symptoms and medication use, as well as a reduction in exposure to environmental tobacco smoke. This program is ongoing, and has been fully integrated into clinic operations.

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