Nemours Alfred I. Dupont Hospital for Children received a $3.6 million CMS grant for a multi-year Health Care Innovation Award that will be used to enhance family-centered health homes by adding services for children with asthma and developing a population health initiative in the neighborhoods surrounding targeted primary care practices. The intervention will also increase coordination of services by integrating care with community support services and local government initiatives to provide healthier environments for children with asthma in schools, child care centers, and housing, and by deploying community health workers to serve as patient navigators and provide case management services to families with high needs. The goal of this model is to reduce asthma-related emergency room use and asthma-related hospitalization among pediatric Medicaid patients in Delaware by 50% by 2015 with incremental declines in 2013 and 2014. This goal will be accomplished by focusing on three distinct strategies:
Enhancement of the family-centered medical home by adding new services for children with asthma and developing a well-coordinated interdisciplinary approach to managing asthma care
Development of a sustainable network of evidence-based supports and services surrounding each of the three targeted primary care sites, using the “integrator” model that Nemours has already adopted
Deployment of a “navigator” workforce that incorporates non-medical needs into the provision of care for children with asthma that promotes respiratory health and addresses environmental asthma triggers throughout the target communities
