Childhood Asthma: Considerations for Primary Care Practice and Chronic Disease Management in the Village of Care
Introduction
Primary care practice development and related considerations for approaches to chronic disease management are significant topics in this era of rapid change in health care. The burden of chronic disease in the United States has been increasing, and there has been an increased recognition of the need for primary care to address this problem.1 Interacting issues (the chronic disease model of care, the patient-centered medical home [PCMH], the Patient Centered Affordable Care Act) have developed during the past decade have led to an increased recognition of the need for an advanced model of primary care to improve the health of patients in the context of their families, homes, and communities.2, 3
This article presents a practical question-oriented approach to considerations for chronic disease care, using childhood asthma as an example, to help primary care providers (PCPs) appreciate the wide-ranging concept of advanced primary care. How do primary care practices develop efforts within the context of a PCMH that can be linked to community-based efforts for addressing chronic disease care? Also, specifically, how does a PCP envision the role of an individual practice in the practice neighborhood (community)?4 There is a stated need and new emphasis for PCPs to not only consider a transformed model of care in a PCMH but also shift the paradigm from an individual practice and one-on-one care to population-based approaches, with coordination and integration of care in the medical neighborhood.4 The neighborhood of the medical system includes specialists, health care institutions, and health care teams, and PCPs need to help patients navigate the system to ensure that plans of all entities are coordinated and work together as a whole for patients' health care needs.4 Importantly, the neighborhood can and likely should be extended to include developing better relationships and supports through community services.4 PCPs need to consider a new paradigm of care that includes population-based approaches, positioning their practice efforts within a broader context of health care at a community level and developing a community-included system integration model of care for chronic diseases.
However, as much as there is a developing emphasis on providing a supportive primary care environment and PCMH, it is important to recognize that the real medical home is the patient's home. In other words, using the example of childhood asthma, children and their families must be seen as central to addressing their issues in care and to making health care most effective. We need to find new and innovative ways to reach children and their families, via a potential array of community-based services and supports, and work with them to improve care.
This article highlights the value of community-based contributions to childhood asthma care and discusses how that value might be linked to evolving practice and health system needs. It underscores the concept of enhancing practice connections to local community services to build a local “village of care.”
Section snippets
Question 1: why does this relate to my practice and the care I provide
Traditional medical training, in both medical school and primary care residencies, has emphasized care of the individual patient. Even when the context of patient care has been expanded to the understanding of inclusion of the family within the home and the home environment, there has been a disconnection, much more often than not, from the consideration of the people living in their community, the village of care. The community has its own culture, attitudes, and beliefs about health and
Question 2: why should we use childhood asthma to consider a model of advanced primary care
Despite a redefinition of the approach to and care for childhood asthma more than 2 decades ago (eg, routine use of anti-inflammatory medications, such as inhaled corticosteroids for persistent asthma) under the National Asthma Education and Prevention Program (NAEPP), the incidence of childhood asthma has increased to historically high levels and disparities in care remain high.5, 6, 7 Furthermore, high rates of emergency department (ED) visits and hospitalizations indicate a lack of control
Question 3: why is it important to control childhood asthma
Childhood asthma is frequently underappreciated in terms of its effect on children, families, and the costs of health care. It is the most prevalent chronic disease in children and causes absenteeism from school (a marker for poor school performance), missed workdays for parents, and lost productivity for employers.5, 6, 7, 11, 12, 13 Costs of medical care related to unnecessary or excessive ED visits are high, as well as hospitalizations for children with uncontrolled asthma. In the United
Question 4: why has it been difficult to control childhood asthma
Asthma is a multifactorial illness with a variety of causes and triggers. Identification and removal of triggers can be problematic. Common triggers and/or environmental irritants may include outdoor air quality (pollution, fumes), indoor air quality, environmental tobacco smoke, mold, pets, rodents, dust, and many others.5, 6, 9
Furthermore, the transient intermittent nature of childhood asthma often results in decreased understanding and underestimation of the disease or its importance.7, 11,
Question 5: how does the Affordable Care Act apply to these considerations for childhood asthma and chronic disease care
The Patient Protection and Affordable Care Act (ACA), signed into law in March, 2010, will have far-reaching effects for fostering change in primary care practice. Emphasis is placed on “reaching” the practice population at risk, electronic health records with “meaningful use,” developing patient registries (eg, all children in a practice with asthma), coordination of care, and incentives for improved patient outcomes, and there is an expanded emphasis on community-based care. These emphases of
Questions 6 and 7: what is the importance of childhood asthma in the context of the Chronic Care Model and how do we reach those who cannot be reached
Plumb and colleagues in an article elsewhere in this issue discuss the importance of community-based partnerships for improving chronic disease management. The investigators emphasize the importance of expanding the Chronic Care Model developed by Wagner and colleagues to include community-based approaches to enable patients and families to become better, informed partners in care.21, 22, 23 Furthermore, Plumb and colleagues develop the concept that the Social Ecology Model can provide the
Question 8: what have we learned from community coalition examples to address the burden of childhood asthma
Two national multisite projects (Allies Against Asthma, Robert Wood Johnson Foundation; Merck Childhood Asthma Network [MCAN], Merck Foundation),13, 24 developed via foundation support, provide examples and considerable insight into the ability of communities to form coalitions and collaborative approaches to address the burden of childhood asthma. The key tenet for both efforts relies on the capacity of a coalition or collaborative partnership to bring many local stakeholders together to form
Question 9: how do these experiences with large community coalitions relate to developing integrated practice and community-based approaches in a local community on a smaller scale
The community coalition experiences described earlier indicate the ability to assess community needs and bring stakeholders together to plan effective programs for childhood asthma care and services in a variety of communities. Every primary care practice exists within the context of its own community. The people or families that any practice serves are community members who are affected by the community's circumstances, economics, institutions, structure, supports, and services. Each practice
Question 10: how do we link community-based approaches with practice-based approaches to care
For the provider in primary care practice, it may seem beyond the scope of care to include community-based care and services in a practice-based approach. This article is intended to encourage thought about how to consider expanding the reach of care to create a more coordinated, comprehensive, and inclusive arrangement of practice and community-based services to support children with asthma, and their families, to improve outcomes in care. As the health system moves toward a higher degree of
Summary
The example of childhood asthma can help us to understand the importance of the awareness of the many social, economic, environmental, behavioral, and cultural aspects of care that contribute to better health outcomes. The care for children with asthma depends on the many factors and influences of life beyond the office time spent with the children and their families or caregivers. Our ability to be more successful as PCPs will be greatly enhanced by building connections to, integrating with,
Acknowledgments
The author acknowledges the many colleagues and partners who participated in the Robert Wood Johnson Foundation Allies Against Asthma Coalitions and the Merck Childhood Asthma Network of the Merck Foundation. Also appreciated are the efforts of the staff of the Health Promotion Council of Southeastern Pennsylvania, which served as the infrastructure organization supporting the Philadelphia Allies Against Asthma Coalition and the Philadelphia Merck Childhood Asthma Network Project.
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The author has nothing to disclose.