PAGNY Physicians Pioneer Community-Based Program to Improve Medical Care for Asthma Patients

A novel program developed by PAGNY physicians at NYC Health + Hospitals/Lincoln could be a model to attack the scourge of asthma in neighborhoods where the asthma rate far exceeds the national average.

With the help of a five-year, $900,000 state grant, Lincoln and its community partners in the South Bronx have created a program aimed at improving treatment and awareness of asthma in order to reduce hospitalizations and improve the quality of life for many thousands of Bronx residents.

“The magnitude of the problem in the Bronx is enormous,” says Dr. Balavenkatesh Kanna, Associate CMO, Patient Safety Officer and Chair of PAGNY’s Research and Education Committee. “We have created a successful model for the health care system to handle the enormous burden of asthma. Our goal is to improve the quality of care for asthmatics at highest risk and decrease Emergency Department visits.”

Bronx County has some of the highest asthma rates in the country. Hospitalizations due to asthma are five times higher than the national average and in some neighborhoods—especially in the South Bronx, where Lincoln is located — it is estimated that 20 percent of children suffer from asthma.

The state grant led to the creation of the Bronx Regional Asthma Coalition (BRAC), which formed a program called RESPIRAR (Spanish for breathe) that targets schools, day care centers and other community organizations to educate participants on how to treat and manage asthma.

“We serve as a community coalition, bringing together partners to unite the forces that are trying to improve the burden of asthma,” says Tomas Jimenez, RESPIRAR’s Asthma Care Manager. The Program Directors are Dr. Kanna and Dr. Riyad Basir, Chief, Pulmonary & Critical Care at NYC Health + Hospitals/Lincoln.

The program educates Lincoln’s asthma patients and community residents about preventive care, taking their medication, undergoing the correct pulmonary tests and going to follow-up visits with their doctors. In addition, the program last year began working with the Segundo Ruiz Belvis Neighborhood Family Care, a South Bronx clinic that focuses on treating asthma patients. The program also includes a home assessment team that helps residents reduce asthma risks in the home.

“The BRAC team makes sure care is coordinated effectively so patients don’t come back to the Emergency Department,” Dr. Kanna says. “We try to prevent exacerbation of asthma by supporting the clinic and their high-risk patients.”

RESPIRAR has a large interdisciplinary team. Its members include:

• Dr. Riyad Basir, Chief of Pulmonary and Critical Care
• Dr. Balavenkatesh Kanna; Associate CMO and Patient Safety Officer
• Dr. Sandra Scott, Chief of Emergency Department
• Dr. Christina Ho, Asthma Champion, Adult ED
• Dr. Shefali Khanna, Chair of Pediatrics
• Marly Caraballo, RT, Director, Respiratory Therapy
• Mary Perez, Adult Pulmonary Clinic Coordinator
• Thelma Bramble, RN, Head Nurse, Adult Pulmonary Clinic
• Maria Molina, AE-C, Asthma Educator, Adult Pulmonary
• John Zhang, Health Analytics
• Cheryl Simmons-Oliver, Associate Executive Director, Community & Public Affairs
• Adora Campis, Coalition Coordinator
• Tomas Jimenez, Asthma Care Manager.

“With asthma entrenched in the Bronx, the purpose of BRAC is to create good models of care,” Dr. Kanna says. “NYC H+H is already using this model for asthma care. We have a lot of experience and we know what works and doesn’t work. Hopefully, that experience can be adopted by larger programs.”