IMPLEMENTING AN ASTHMA

HOME VISIT PROGRAM:

10 Steps To Help

Health Plans

Get Started

United States

Environmental Protection

Agency
This document shares the experiences of seven health care organizations

that offer asthma home visit programs. It is intended to provide health

insurance plans with general guidelines—based on the experience of other

health care organizations—on what to consider when incorporating a home

visit program into an existing asthma management program. The content in

this document does not represent official EPA policy or guidance.
3

The U.S. Environmental Protection Agency (EPA) has

launched a nationwide asthma public education and

prevention program. The goal of this program is to

make the public and the medical community more

aware of environmental asthma triggers and simple

ways to reduce exposure to these triggers, especially

at home.

Along with proper medical treatment, effective

management of environmental triggers in the home 

can reduce the number and severity of an individual’s

asthma episodes. This reduction may result in fewer

emergency room visits and hospitalizations, increasing

a person’s quality of life and reducing health plans’

cost of care.

Home visits are one way to give enrollees the tools 

they need to address their asthma effectively as part

of a comprehensive disease management program

incorporating medical and environmental management

techniques. EPA developed this guide with input from

seven health care organizations that offer asthma 

home visits as part of their comprehensive asthma

management programs. It incorporates their

experiences establishing and operating home visit

programs, and reflects their belief in the value, both 

to the enrollees and to the health insurer, of such

programs.

HOW TO USE THIS GUIDE

This guide should be used

primarily by health plans that have

established asthma management

programs. It offers step-by-step

instructions on how to implement

an asthma home visit program

with a particular emphasis on

environmental risk factor

management. The guide is

organized around 10 essential

steps in the implementation

process, from program inception

to program evaluation:

1. Learn about the benefits of 

a home visit program as 

part of a traditional asthma

disease management

program.

2. Get your health plan’s

leadership to buy into the

program.

3. Form an implementation

team.

4. Develop the structure of 

the home visit program.

5. Determine which enrollees

will be visited at home.

6. Develop outreach strategies.

7. Determine what outcomes

and outputs will be

measured and how they 

will be measured.

8. Develop tools and forms 

and train staff.

9. Form relationships or

partnerships with community

asthma organizations.

10. Implement the program and

track its results.

The guide also provides

references to additional 

resources you may want to

consult. These resources provide

information on asthma, asthma

disease management, and asthma

home visit programs.
Program Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Prevalence and Costs of Asthma . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Environmental Risk Factor Management . . . . . . . . . . . . . . . . . . . . . 1

Asthma Home Visits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

10 Steps to Help Health Plans Get Started . . . . . . . . . . . . 4

Learn about the benefits of a home visit program as part of

a traditional asthma disease management program . . . . . . . . . . . . 4

Get your health plan’s leadership to buy into 

the program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Form an implementation team . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Develop the structure of the home 

visit program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Determine which enrollees will be visited at home . . . . . . . . . . . . . 9

Develop outreach strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Determine what outcomes and outputs will be 

measured and how they will be measured . . . . . . . . . . . . . . . . . . . . 11

Develop tools and forms and train staff . . . . . . . . . . . . . . . . . . . . . . 12

Form relationships or partnerships with 

community asthma organizations . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Implement the program and track its results . . . . . . . . . . . . . . . . . . 14

A Final Note . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Asthma Resources . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Contents

4
Prevalence and Costs 

of Asthma

The Centers for Disease Control and

Prevention (CDC) estimate that more

than 20 million people in the United

States have asthma, including 6.1 million

children.1 Asthma is responsible for

nearly 500,000 hospitalizations, 1.9

million emergency department visits, and

more than 4,000 deaths annually. In the

United States, members of certain racial

and ethnic groups are at greater risk of

suffering and dying from asthma. Health

care costs ($11.5 billion) and indirect

costs (such as lost productivity from

missed school and work days) bring the

total cost of asthma to $16.1 billion

annually.2

Although the reason for the increasing

prevalence of asthma cases is not well

understood, the factors that cause

asthma episodes—and the means of

preventing and controlling episodes—are

well defined. To serve their enrollees

better, many health plans have developed

chronic disease management programs

for the treatment of asthma. In fact,

according to a 2002 survey by America’s

Health Insurance Plans (AHIP), 83

percent of health maintenance

organizations (HMOs) and point of

service (POS) plans report having a

disease management program for

asthma.3

Health plans continue to adopt asthma

disease management programs in an

effort to provide comprehensive health

services to their enrollees.

Environmental Risk

Factor Management

While asthma cannot be cured, it is 

most effectively controlled with

comprehensive care that includes medical

and environmental management

techniques. The National Institutes of

Health (NIH) acknowledges that the

indoor environment is an important

factor in the growing asthma problem.

For successful long-term asthma

management, NIH recommends a

comprehensive program of assessment

and monitoring, medication, patient

education, and control of factors that

contribute to the severity of asthma.4

These factors can include inhaled

allergens and irritants (indoors and

outdoors), exercise, certain foods and

medicines, and viral respiratory infections.

NIH’s National Heart, Lung and Blood

Institute (NHLBI) says in its Guidelines

for the Diagnosis and Management of

Asthma that exposure of sensitive

patients to inhalant allergens has been

shown to increase airway inflammation,

airway hyper-responsiveness, asthma

symptoms, need for medication, and

death due to asthma. Irritants, such as

secondhand smoke, are associated with

decreased levels of pulmonary function,

increased requirements for medication,

and more frequent absences from work.

Exposure to a mother’s secondhand

smoke is a risk factor for developing

asthma in infancy.5

At the request of EPA, the National

Academy of Sciences (NAS) assessed the

relationship between indoor air

exposures and asthma. NAS’s goals in

examining chemical and biological

agents that might affect asthma were to:

• Provide the scientific and technical

basis for communications to the

public on the health impacts of

indoor pollutants related to asthma

and on mitigation and prevention

strategies to reduce these

pollutants.

• Help to determine what research is

needed in these areas.

NAS’s report, Clearing the Air,

concluded that:

• Exposure to secondhand smoke,

nitrogen dioxide and indoor

allergens—dust mites, cockroaches,

pet dander, and mold—can make

asthma symptoms worse.

• Exposure to dust mites can cause

children of any age to develop asthma.

• Exposure to secondhand smoke can

cause preschool-aged children to

develop asthma.6

Program Overview

1
Given these relationships, an essential

part of a comprehensive asthma

management program is identifying and

reducing exposures to allergens

(especially inhaled allergens) and irritants

that can increase or exacerbate asthma

symptoms (i.e., environmental “triggers”).

This strategy of reducing exposures to

environmental triggers is consistent with

and supports the national guidelines.

These environmental triggers are listed

below.7

DUST MITES

Triggers: Body parts and droppings.

Where Found: Highest levels found in

mattresses and bedding. Also found in

carpeting, curtains and draperies,

upholstered furniture, and stuffed toys.

Dust mites are too small to be seen with

the naked eye and are found in almost

every home.

PESTS (SUCH AS COCKROACHES

AND RODENTS)

Triggers: Cockroaches – Body parts,

secretions, and droppings.

Rodents – Hair, skin flakes, urine, and saliva.

Where Found: Often found in areas

with food and water such as kitchens,

bathrooms, and basements.

WARM-BLOODED PETS (SUCH AS

CATS AND DOGS)

Triggers: Skin flakes, urine, and saliva.

Where Found: Throughout entire house,

if allowed inside.

MOLD 

Triggers: Mold and mold spores, which

may begin growing indoors when they

land on damp or wet surfaces.

Where Found: Often found in areas

with excess moisture such as kitchens,

bathrooms, and basements. There are

many types of mold and they can be

found in any climate.

SECONDHAND SMOKE

Trigger: Secondhand smoke – Mixture of

smoke from the burning end of a

cigarette, pipe, or cigar and the smoke

exhaled by a smoker.

Where Found: Home or car where

smoking is allowed.

NITROGEN DIOXIDE (COMBUSTION

BY-PRODUCT)

Trigger: Nitrogen dioxide – An odorless

gas that can irritate eyes, nose, and throat

and may cause shortness of breath.

Where Found: Associated with gas

cooking appliances, fireplaces,

woodstoves, and unvented kerosene and

gas space heaters.

While developing its asthma education

program, EPA recognized that public and

private health plans are in a good position

to address environmental risk factor

management because health plans serve

people with asthma, their families, and

their primary care providers. In addition,

health plans pay a substantial portion of

the $11.5 billion spent annually to treat

asthma. Consequently, EPA is reaching

out to health plans to encourage them to

incorporate environmental risk factor

management in their asthma disease

management programs. One technique

for introducing people with asthma to

environmental risk factor management is

the home visit. Recent studies continue

to support home-based interventions

tailored to meet an individual’s sensitivity

and exposure to environmental triggers.8

2
Asthma Home Visits

Home visits provide an opportunity to educate people with asthma and to help

them effectively manage their disease by participating in asthma management

programs developed with their primary care physicians (PCPs). A home visit

provides an ideal setting to educate, review medication plans, and help families to

identify environmental factors in their homes that may contribute to the severity

of asthma.

The primary purpose of a home visit is to identify and mitigate the effects of

exposure to environmental triggers in the home. Going to the family’s home can

be very effective because more information can be learned from, and given to, a

person face to face at home than over the telephone or in a doctor’s office. At the

same time, the asthma management team can use the visit to assess the indoor

environment where a person spends much of the day and evaluate firsthand

sources of triggers and potential pathways that may lead to asthma flare-ups.

Home environmental assessment for asthma triggers has the potential to improve

an individual’s and the family’s understanding and skill development to manage

asthma effectively. In addition, PCPs can use the results of the environmental

assessment to understand the context of exposure better and tailor treatment

accordingly.

3
Learn about the benefits of a 

home visit program as part of a

traditional asthma disease

management program.

The use of home visits to incorporate environmental risk

factor management into traditional asthma management

programs offers many benefits. Understanding how

environmental risk factor management benefits enrollees and

the health plan is critical to justifying a home visit program

and obtaining the support of health plan executives.

A health plan that already has an asthma management

program is probably realizing a return on its investment. By

building on the existing infrastructure and investment, and

by adding environmental risk factor management through

home visits (thus enhancing asthma management), the plan

may expect to increase its return further. Environmental risk

factor management can provide medical, financial, and economic

benefits, as well as public relations or competitive advantages.

• Medical benefits. Enrollees may experience overall

improvements in their quality of life as well as

decreased symptoms, fewer severe episodes requiring an

emergency department (ED) visit or hospitalization,

and improved preventive care and self-management of

their asthma.

• Financial benefits. The health plan and payers may

save on costs when rates of hospitalizations and ED

care decrease. Enrollees benefit financially by missing

fewer work days and may also benefit by spending less

on costly emergency care.

• Economic benefits. Payers and society benefit from

increased productivity from fewer missed work and

school days.

• Public relations or competitive advantages. Many

health plans stress strong disease management to

differentiate themselves from the competition. A

comprehensive asthma management program that

includes environmental risk factor management further

demonstrates the health plan’s commitment to quality

care. Given the prevalence of asthma in the United

States, many prospective enrollees look for asthma

management programs, and a comprehensive program

that includes home visits can give a health plan a

competitive advantage.

A detailed marketing strategy built around environmental

risk factor management might include these points:

• Helping enrollees reduce their exposure to indoor

triggers may improve overall indoor air quality and

benefit others in the household.

• This approach promotes community involvement (from

the plan, providers, enrollees, and other organizations)

in managing asthma.

• Health care providers will be given the tools necessary

to manage asthma comprehensively.

10 Steps To Help Health Plans Get Started with 

Asthma Home Visits

4

PMPM Costs and Savings, Pre- and Post-Home Visit Program

Category of Service Pre-Home Visit Program Post-Home Visit Program Savings PMPM 

PCP/specialist costs* $12.30 $9.10 $3.20

ED visit costs* $13.85 $11.99 $1.86

Inpatient admission costs* $112.07 $38.77 $73.30

Home care costs $1.00 $4.53 ($3.53)

(includes asthma 

program home visits and 

non-asthma program 

home health care)

Total $139.22 $64.39 $74.83

* With primary diagnosis of asthma

CASE STUDY 1— COST SAVINGS

One Mid-Atlantic health plan saw dramatic cost savings and improved health outcomes within 6 months of enrolling people with

asthma in its home visit program. The plan saved $74.83 per member per month (PMPM) after instituting a home visit program.

Participating enrollees had significantly fewer hospitalizations, fewer emergency department visits, and fewer urgent physician

visits. Preventive medication use increased, while the use of “rescue” medications decreased, an indication that the enrollees

were managing their disease better.

The chart below shows the per-member-per-month costs and savings across the entire asthma enrollee population (about 8,000

members out of a total membership of about 300,000) that resulted from the home visit program. 

1.
Get your health

plan’s leadership to buy

into the program.

Raising key executives’ awareness of the

program is crucial. Determine which

executives need to approve and support a

home visit program, such as the Chief

Executive Officer, Chief Financial Officer,

Chief Medical Officer, or Medical

Director. Explain the program and the

medical, financial, economic, and public

relations benefits of incorporating

environmental risk factor management

and home visits into traditional clinical

asthma management programs.

Be prepared to present the home visit

program’s operational details as they are

developed (from Steps 4 to 9), its

estimated costs, and its potential savings.

Determine necessary resources (in

addition to current expenditures if an 

asthma management program is already in

place), prepare a budget, and obtain the

necessary commitments from upper

management. Budgets should include:

• Staff time to develop the program.

• Development of educational

materials and a case management

protocol.

• Staffing for the program or

outsourcing costs.

• Ongoing operational costs including

resources for data gathering and

analysis.

It may also be helpful to estimate

program costs in accordance with the

health plan’s underwriting practices. For

example, many health plans evaluate the

cost of their programs on a per-memberper-month basis.

A pilot program may be a good way to

demonstrate positive health outcomes

and financial savings before executives

make a long-term commitment. The

same health plan highlighted in Case

Study 1 on page 4 decided to offer a

home visit program to all of its enrollees

with asthma after conducting a pilot with

50 severe pediatric asthmatics. Nurses

were sent to the homes of these 50

enrollees to educate the families about

the disease and proper self-care. Within 6

months of the home visit, the plan saw a

dramatic improvement in utilization.

Participating enrollees had significantly

fewer hospitalizations, fewer emergency

department visits, and fewer urgent

physician visits. Preventive medication use

increased, while the use of “rescue”

medications decreased, an indication that

the enrollees were managing their disease

better. Although a pilot need not involve

a large number of enrollees, it should be

able to measure changes in clinical

outcomes, such as claims utilization and

quality of life assessments, to show

program benefits.

Form an

implementation team.

A health plan that has an asthma

management program that does not yet

include home visits may already have in

place a team that could implement a

home visit program. This team may

consist of the individuals who developed

or run the current asthma management

program.

If a health plan must form a new team, it

likely will include the Medical Director,

Health Services Director, Director of

Utilization Management, Director of

Quality, asthma case manager (if an asthma

program already exists), one or two

network physicians with a significant

asthma patient load, a data programmer

or analyst, and a person with asthma or

their caregiver. The person with asthma

or the caregiver may be able, based on

their own experience, to suggest ways to

overcome implementation barriers, such

as resistance to or unavailability for home

visits.

The implementation team should initially

meet at least monthly to start developing

the program’s details, including its goals,

components, and implementation plan

(e.g., whether to outsource, number of

home visits provided) and its participant

eligibility criteria. Steps 4 to 9 provide

additional information on specific

development activities. The team should also

develop a realistic implementation schedule.

5

2.

3.
Develop the structure 

of the home visit program.

A. Determine program goals

The first step in structuring a home visit program is to

determine the program’s goals. Goals may relate to the

number and characteristics of enrollees the program will

serve, or the health outcomes and cost savings desired.

Goals can also express less tangible outcomes such as

strengthening ties with community organizations or

increasing PCPs’ knowledge of environmental risk factor

management. The implementation team may want to begin

collecting baseline data that will provide a point of

comparison for the outcomes and outputs selected for

tracking (see step 7).

B. Define major components of the home visit program

Once the program’s goals are defined, several factors should

be considered when designing the program components.

These factors include the number of enrollees estimated to

be eligible for the program (see Step 5), individual patient

needs, and available resources (monetary and staff). Above

all, the program should be tailored to the needs of the

organization and its members. If the proposed program

would involve a change in the benefit structure, sample

benefit language should be drafted. It should be presented

to key executives along with the proposed program

structure. The major components of a home visit program

that should be considered include:

• Individual Asthma Action Plan. Most plans that 

have asthma management programs stress the need for

individual action plans if self-management of asthma is

to succeed. During the home visit, the home visit

provider can introduce the concept of self-management

and provide instruction in how to develop, with the

help of a physician, a personal plan that includes

controlling environmental triggers.

• General Asthma Education. Some plans use the

home visits to educate enrollees on asthma issues

broader than environmental risk factor management.

Topics may include general disease comprehension;

appropriate medication use; use of equipment such as

peak flow meters, spacers, and nebulizers as necessary

for self-management; and guidelines for appropriate

care utilization. Some health plans use tests (before 

and after the home visit) to assess the effectiveness of

their educational efforts, measuring such factors as

acquisition of appropriate skills.

• Environmental Assessment. An assessment survey

form or checklist may be helpful in searching for and

identifying potential indoor triggers. Home visit

providers should look for indicators of the presence of

common triggers (e.g., dust mites, pests, pets, mold,

secondhand smoke, and nitrogen dioxide) throughout

the home. The home visit provider should give special

attention to the sleeping area. The checklist may also

address other issues, such as housing defects that

contribute to the presence of triggers or the impact of

outdoor air pollution on asthma. See Step 8.A for a

description of EPA’s Asthma Home Environment

Checklist.

• Environmental Trigger Education and Mitigation.

If sensitivities to particular indoor triggers are known,

the home visit assessment should begin by focusing on

exposures relevant to these sensitivities. If a trigger is

found, the home visit provider should explain how the

trigger affects the person’s condition and provide

advice on how to reduce exposure to the trigger.

Recommendations should be viable for the enrollee’s

means and conditions (e.g., keeping pets out of the

bedroom, smoking outside the home and car,

frequently washing bed linens and stuffed toys in hot

water). Depending on the plan’s benefits, providers

could refer enrollees to smoking cessation programs,

offer trigger-reducing items such as dust-proof

(allergen impermeable) bed and pillow covers, or

provide hands-on assistance in educating enrollees

about mitigation techniques. Health plans need to

communicate clearly the extent of the services they will

provide to the enrollee.

Health plans that serve a low-income population

should carefully consider the effort that will be

required to make their home visit programs successful.

They should realistically evaluate whether their benefit

structure and operating budget will allow for the

services that a low-income population would need.

Making social service referrals, providing products at

no cost, and providing hands-on assistance and

instruction with product usage and other mitigation

techniques are essential for a low-income population.

• Resource Referral. Information about community

resources—including those that focus on asthma and

those that address related social needs—may be given

to the enrollee when appropriate and available. For

example, a renter who cannot easily address his or her

6

ENCOURAGING THE 

USE OF ASTHMA ACTION PLANS

Some plans provide monetary incentives to 

providers for quality performance, including completion

of asthma action plans. One Midwest plan experienced

a 162 percent increase in the number of action plans

between 2000, when the program was 

implemented, and 2002.

4.
building’s mold problems may

benefit from a referral to a tenant

advocacy organization or the local

housing authority. Local asthmafocused organizations may be able

to help enrollees obtain allergenreducing items. See Step 9 and Case

Study 5 for more information on

using community resources.

• Recordkeeping and Reporting.

An important component of a home

visit program is recordkeeping and

reporting. Health plans will want to

record and track information to:

• See how individual enrollees

are affected.

• Assess improvements in the

home visit program

participants’ symptoms.

• Calculate cost savings or other

benefits to the health plan.

When designing a home visit

program, a health plan will

need to determine how data

will be collected, aggregated,

monitored, tracked, and

reported. Steps 7 and 8 discuss

more fully the information

health plans may consider

tracking.

• Follow-up. The home visit program

may include some form of follow-up

with the enrollee, either by

telephone or an additional home

visit, to assess compliance with

recommendations, track overall

progress, and support continued

self-management.

• When to follow up. When

the follow-up is conducted will

depend on the health plan and

its outreach capabilities; many

plans report following up one

week to one month after the

initial visit.

• How to follow up. The

frequency and intensity of

follow-up could depend on 

the enrollee’s self-care ability.

This could be determined by

demonstration of new skills 

or changes in behavior, as well

as an ongoing review of the

enrollee’s asthma symptoms,

episodes, and use of urgent

care. Many plans do not make

follow-up home visits if the

telephone follow-up and

utilization data clearly show

that an enrollee is managing

his or her disease effectively. 

C. Determine number of home visits

to be provided

The decision on the number of home

visits to provide should consider several

factors, including:

• Who will receive home visits.

• The information to be collected.

• The extent of the home visit

provider’s responsibility for

education and mitigation.

• The specific goals and health outcomes

the visits are meant to accomplish.

• Budgetary constraints.

• Enrollee follow-up required to

achieve desired outcomes.

• Cultural and language issues,

including the need to establish trust

before conducting an assessment.

While many plans have succeeded with

only one or two visits per enrollee, some

provide as many as six visits. One option

is to develop a flexible program that

provides enough home visits for an

enrollee to achieve the desired health

outcomes. That number may be

determined by several techniques,

including:

7

COMPLIANCE WITH THE

HEALTH INSURANCE

PORTABILITY AND

ACCOUNTABILITY ACT (HIPAA)

HIPAA requires certain notifications

and disclosures to people using

health care services to protect the

privacy of their medical records. 

Information collected under a home

visit program must be handled

according to HIPAA regulations,

consistent with a plan’s compliance

policies and practices.
• Pre- and post-visit asthma management program

knowledge tests to determine how many home visits

the enrollee needs.

• A telephone follow-up after the initial visit. The case

manager may identify issues that indicate additional

home visits are necessary. These issues include a lack of

progress, worsening symptoms, or continued

demonstration of limited knowledge of the disease.

D. Determine who will conduct the home visits

This step has two components: deciding what sort of

professional should conduct the home visits, and deciding

whether the visits should be performed by health plan staff

or by a third party vendor.

A variety of professionals can conduct home visits:

respiratory therapists, nurses, social workers, asthma

management program case managers, home health care

workers, and community outreach workers. The skills

appropriate for a home visit program will depend on its

goals, the type of education or mitigation to be provided,

the budget, and the availability of personnel. Each group of

professionals has potential advantages. For example,

respiratory therapists will be very familiar with asthma and

its treatment. Nurses and social workers may be able to take

a broader view and pay more attention to possible psychosocial issues. Asthma management program case managers

(who may be medical or non-medical personnel) may also

take a broad view of the enrollee and his or her family.

Home health care and community outreach workers may be

more attuned to local cultural or language issues. If the

home visit program will address both medical and

environmental issues, the home visit provider must be

capable of addressing both competently.

Besides deciding what sort of professional should conduct

home visits, a decision must be made on whether to use a

third party vendor or health plan staff. Each option has

strengths and weaknesses, as shown below in Exhibit 1. The

goals of the program and the characteristics of a plan’s

enrollees (e.g., population demographics, size, asthma

severity) can offer guidance.

Case Study 2 on page 9 shows how both in-house staffing

and outsourcing can be effective.

The staffing decision may also be influenced by funding or

payment options. As described in Case Study 2, several

health plans have obtained grants to pay for additional inhouse staff for home visit programs. In addition, one

Midwest plan received a grant from the Department of

Housing and Urban Development’s Healthy Homes

program that allowed it to pay for thorough home

environmental assessments by an environmental specialist.

Health plans may also be able to develop alternatives that

address potential staffing issues. For example, while

outsourcing may seem to be the best way of addressing a

culturally diverse population, a health plan may have

multilingual staff who are appropriate and available for this

activity.

8

Exhibit 1. Characteristics of Program Staffing Options

Consideration or Goal Health Plan Staff Third Party Vendor

Coverage of all members with asthma May be more efficient as it may

not require additional in-house

staff to serve large population

Monitoring and tracking outcomes Communication and tracking are generally 

easier because staff members are often linked 

to the same telephone and computer system

Culturally diverse enrollee population May specialize in

communicating with culturally

diverse populations

Quality control and accountability May be more accountable because they share 

the same organizational goals

Expertise in asthma care May have specialists, such as

respiratory therapists, who are

knowledgeable about asthma

and familiar with equipment and

techniques used for selfmanagement
E. If using an outside vendor, develop and negotiate

contracts and payment terms

If home visits are outsourced, they could be paid for on a per

visit or per case basis. This decision depends on how many

home visits are expected and on their specific goals. A case

rate may be more effective when several visits per enrollee are

anticipated. Case Study 2 provides additional information on

how some plans pay for vendor services.

Third party contractors should be clear about program goals

and the plan’s expectations for the visits. Adequate reporting

is essential, both to assure quality and to determine

subsequent outcomes.

Some health plans have successfully partnered with nonprofit organizations, rather than contracting with

commercial vendors, who conduct home visits at no or low

cost to the health plan. This option should always be

explored. (See discussion in Step 9 for further information.)

Determine which enrollees will be

visited at home.

Depending on their available resources and the size of their

asthma enrollee population, some plans offer home visits to

all enrollees with asthma while others visit only those

enrollees with the most severe asthma. Many plans believe

that telephonic care management and regular patientphysician interaction are sufficient for the enrollees with

mild cases of asthma—and often for enrollees with moderate

cases as well. These enrollees often improve from simple

instructions on how to use their medications appropriately.

Telephonic care management should also cover

environmental triggers to help enrollees assess their homes.

Those with the most severe asthma, however, have the

greatest potential to benefit from home visits. They may not

be knowledgeable about environmental triggers, may be

unaware that they have regular contact with triggers in their

homes, and, in some cases, may have other complicating

issues. Whether a home visit program will be offered to

some or all of a plan’s enrollees with asthma, there must be

9

STRATIFYING ASTHMA SEVERITY

Standard classifications identified by NHLBI’s Practical

Guide for the Diagnosis and Management of Asthma:

• Mild intermittent 

• Mild persistent

• Moderate persistent

• Severe persistent

CASE STUDY 2 - THIRD PARTY VENDOR VERSUS HEALTH PLAN STAFF

Many plans base their staffing decision on factors such as service area, community needs, and funding. For example, plans

serving large geographic regions or large populations tend to outsource visits to third party vendors, while smaller plans serving

local areas can use health plan staff effectively to conduct home visits. The cases below describe the decisions and rationale of

four plans.

THIRD PARTY: LARGE SERVICE AREA AND COMMUNITY NEEDS

• A Northeast metropolitan health plan, Plan A, relies on respiratory therapist (RT) vendors to conduct home visits for

its large, urban population. The plan believes these providers are more familiar with asthma and the equipment used

in its treatment than the home health care nurses they formerly employed. Plan A pays the vendors $75 per visit, plus

the cost of certain necessary medical equipment provided by the vendor.

• Plan B, another Northeast health plan, contracts with RTs and home health care nurses to conduct the visits. It

prefers to outsource rather than to maintain the large staff that would be needed to cover the service area (the entire

state). Plan B also knows that the vendors are very familiar with their local communities. Plan B pays $80-$125 per

visit, depending on the particular contract.

HEALTH PLAN STAFF: ACCOUNTABILITY AND QUALITY CONTROL

• A large Mid-Atlantic health plan, Plan C, contracts with home health agencies that are part of the same health system

as the health plan. This plan thinks that there is better accountability and quality control when working with an in-plan

provider. Plan C pays its home health vendor a case rate of $425 to provide as many visits as needed.

• A West Coast county-based plan, Plan D, started its program as a Health Plan Employer Data Information Set (HEDIS)

demonstration project. The health plan employs one nurse who is solely responsible for asthma disease

management. She designs and leads community education programs and makes about 40 home visits per month.

Because she works only with the health plan’s membership, she has been able to recognize enrollees’ needs and

adapt the program to serve that population better. She believes that there is “more control” when the visits are kept

in-house. Recently, Plan D received a Health Resources and Services Administration (HRSA) grant to add an

additional nurse and outreach worker in order to expand the program and provide more home visits. Operational

costs include the salaries and equipment used by the nurses and outreach worker. 

5.
a mechanism to identify them. Health plans that have

asthma management programs identify enrollees with

asthma through various means that include:

• Welcome calls.

• New member health assessment surveys.

• Asthma utilization reports (e.g., office visit claims data,

ED and hospitalization claims, inpatient claims,

pharmacy claims).

• Physician referrals.

• Case manager identification (e.g., at time of ED or

hospital admission or discharge).

• Computerized disease registries.

After enrollees with asthma have been identified, data from

one or more of the sources listed above can be used to

gauge the severity of their asthma. Stratification of enrollees

by zip code may allow plans to focus resources on areas with

disproportionately higher rates of asthma. (Most plans use at

least the asthma utilization reports.) Case Study 3 describes

how one plan ranks its enrollees with asthma by disease

severity.

Plans with multiple payers with different benefits will need

to ensure that enrollee referrals are consistent with the

benefits provided by their payer. In some cases the asthma

case manager or other individual who is familiar with the

benefit structures may need to make referrals for home

visits, rather than the primary care physician.

Develop outreach strategies.

An active, creative outreach program enables a plan to

contact enrollees with asthma—particularly those in the

Medicaid population—in order to schedule and complete

home visits. Outreach to primary care physicians and other

health care providers is also important. An effective outreach

strategy must consider the following questions.

A. Who contacts the enrollees, and how is contact made?

In some plans, the person who will conduct the home 

visit does the scheduling. Other plans have outreach

coordinators, and still others hire or form partnerships with

outside organizations to find the enrollees. (See Case Study 4,

below.) Eligible enrollees generally are called before the

home visit, but some enrollees may not have telephones. In

those cases, a nurse or other outreach professional may try to

find individual enrollees in person.

Most plans will make more than one attempt to reach an

eligible enrollee with asthma. Plans report that, once contact

is made, most enrollees are very receptive to the concept of a

visit “to help with your (or your child’s) asthma.”

B. What are the features of a successful outreach

strategy?

Flexibility and attention to the specific characteristics of the

enrollee population are hallmarks of successful outreach

strategies. For example:

10

CASE STUDY 3 - ENROLLEE GROUPING

Most plans use some combination of disease assessment and utilization data analysis to group their members according to the

severity of their disease. One Mid-Atlantic plan uses a detailed questionnaire about symptoms to rank new members who are

identified as having asthma. The plan applies specific utilization criteria to established members’ claims information to

determine the severity of their disease. Members are considered low, moderate, or high risk based on the following definitions:

Low: Minimal office visits, no ED visits or hospitalizations for asthma, low pharmacy use.

Moderate: One ED visit for asthma in 6 months, and/or inhaled beta-agonist to anti-inflammatory ratio of

3:1 or greater.

High: Two or more ED visits for asthma in 6 months, and/or one or more hospitalizations for asthma, 

and/or inhaled beta-agonist to anti-inflammatory ratio of 5:1 or greater. 

CASE STUDY 4 - OUTREACH STRATEGIES

Many health plans, particularly those serving the Medicaid population, find that there are barriers, such as out-of-date contact

information, to overcome when contacting enrollees to schedule home visits. 

• One Northeast plan contacts PCPs to get the most current telephone numbers and contact information. 

• The same plan often gets enrollees’ most current contact information from pharmacies, when that information is not

available from PCPs. Plan representatives determine where the enrollee last filled a prescription, and then contact the

pharmacy to check for an updated telephone number.

• Another Mid-Atlantic plan works with a local group called Allies Against Asthma, which has a “community ambassador” program.

Community members help to locate hard-to-track enrollees so they can be asked to participate in the asthma home visit program.

6.
• Multi-lingual staff or translation

services are often necessary for

scheduling and completing visits.

• Flexible scheduling (e.g., lunch

hours, nights, weekends) greatly

increases a plan’s chances of visiting

all eligible enrollees.

• Providing an incentive for enrollees

to schedule and complete a specified

number of visits can help an

outreach strategy succeed. Examples

of incentives are:

• Dust-proof (allergen

impermeable) mattress, pillow

case covers, or other

environmental mitigation

equipment or supplies.

• School supplies.

• Telephone cards.

• Gift certificates (especially to

stores selling trigger-reducing

items).

C. How will health care providers find

out about the home visit program?

Whether PCPs and other health care

providers refer patients or recommend

that they participate in a home visit

program can also affect the participation

rate. The health plan should consider an

outreach effort to notify its providers

about the home visit program, explain

enrollee eligibility, describe the referral

and enrollment process, and discuss the

benefits of the program.

Determine what

outcomes and outputs will

be measured and how

they will be measured.

Plans measure the effectiveness of their

asthma management programs in

different ways. The measures used to

determine success should relate to the

goals set in Step 4. In the early months of

a program, outputs (e.g., number of

enrollees with asthma participating in the

home visit program and number of visits

completed) are the easiest measures to

collect. A health plan should be able to

retrieve this information from the system

it uses to track the scheduling and

completion of home visits (discussed

further in Step 8.C). Output information is

useful in determining the reach of the

program. It also provides information on

the level of effort (e.g, number of visits,

number of staff hours necessary to achieve

program goals).

Over the longer term, information should

be collected that shows the program’s

impact on outcomes, such as reduced

asthma ED visits and hospitalizations.

After reviewing several months’ worth of

outcomes data, targets (e.g., a 30-percent

reduction in ED visits) can be set. The

most common health outcomes measured

for enrollees in asthma management

programs are:

• Asthma ED visits (either ED

visits/1,000 or as a percentage of

enrollees in the asthma management

program).

• Asthma hospitalizations (either

hospital visits/1,000 or as a

percentage of enrollees in the

asthma management program).

• Percentage of enrollees with asthma

with high bronchodilator use.

• Anti-inflammatory/inhaled betaagonist ratio (3:1 or greater is cause

for concern).

• Missed days of school or work.

• Written asthma action plans

(percentage of enrollees with

asthma).

• Appropriate changes in behavior

through acquisition of selfmanagement skills. For example, if

the home visit program includes

education about dust mites, laundry

procedures may be assessed

(enrollees in the program are

washing bedding at the

recommended frequency and water

temperature 2 months after the initial

home visit).

• Increased knowledge; for example,

understanding medication usage,

knowing what can trigger asthma,

and understanding how to mitigate

or control those factors.

11

7.
Health plans that offer PCPs information

and resources on environmental risk

factor management also may want to

track the percentage of physicians using

this information and determine whether

they demonstrate more knowledge 

about these topics after exposure to 

the information.

Most plans pick at least two of the

outcome measures listed above,

depending on their reporting capabilities.

(Much of this information comes from

claims data.) ED visits and hospitalizations

are generally the easiest to measure and

can clearly demonstrate the medical and

financial impact of an asthma

management program, especially if a

home visit component has been added to

an existing program. Whether or not a

plan already has an asthma management

program, baseline data on health

outcomes should be recorded before the

home visit program, or as early as

possible after it begins, so its impact can

be determined. Keep in mind that

improvements might not be

instantaneous; plans report that it takes at

least 6 months to a year for the actions to

produce significant results in the data,

although improvement in the day-to-day

lives of each enrollee visited can usually

be seen much sooner.

Develop tools and

forms and train staff.

Health plans that have home visit

programs use most, if not all, of the tools

and forms described below. One or more

members of the implementation team

(discussed in Step 3) should take

responsibility for gathering and

developing the necessary tools and forms

and for training and educating the rest of

the asthma management program team

about home visits. Everyone needs to be

aware of the ways in which the existing

asthma management program will be

different as a result of the new home visit

component. At some plans, many of the

tools and forms described below are

already in place (e.g., asthma action plans

and enrollee tracking and reporting

systems) and only minor adjustments are

necessary. Others will need to devote

more resources to developing the

necessary infrastructure. References have

been given where applicable to help

locate examples.

When developing a training program,

keep in mind that it is also important to

train physicians and other health care

providers. At a minimum, they will need

to know about the program, who is

eligible, when and how to make referrals,

and asthma management program

components to be tracked.

A. Asthma Home Visit Checklist

The checklist provides a comprehensive

list of questions related to environmental

asthma triggers commonly found in and

around the home.

EPA developed a checklist of questions

and action steps designed to help identify

and mitigate environmental asthma

triggers commonly found in and around

the home. The checklist has 13

categories9 to help the home visit

provider focus on the activities or items

in the house that might produce or

harbor environmental triggers. The EPA

Asthma Home Environment Checklist is

provided in an appendix to this Guide. It

can also be downloaded in pdf format

from EPA’s Web site at

www.epa.gov/asthma/pdfs/

home_environment_checklist.pdf.

12

EXAMPLES OF ASTHMA 

ACTION PLANS

Pediatric/Adult Asthma Coalition of New

Jersey (http://www.pacnj.org/)

Regional Asthma Management &

Prevention Initiative

(http://rampasthma.org/AAP%20page.htm)

8.
B. Individual Asthma Action Plan

A written asthma action plan is developed by the enrollee 

and his or her physician or case manager to help in the

management of asthma episodes. This customized plan

encourages the enrollee to self-manage his or her asthma.

Asthma action plans are sometimes called asthma selfmanagement instructions or written guidelines for asthma.

Asthma action plans can be organized in any number of

ways, but the important thing is that the individual action

plans give enrollees and their families information that can

help them manage their asthma. Plans may include a list of

the person’s triggers and how to avoid them, instructions

for taking asthma medicine, information on what to do if a

child has an asthma episode, instructions on when to call a

doctor, and emergency telephone numbers.

Action plans should be created and reviewed with the

enrollee’s physician or case manager and updated at least

once a year.

C. Intake form, form letters, and reports for

communicating with physicians and enrollees with

asthma

Intake forms can be used to record basic information on an

enrollee newly referred to or identified for the home visit

program (e.g., symptoms, asthma history, physician,

medications). Information on this form can be entered into

a computer system, as discussed in 8.D below. Plans that

have home visit programs use form letters such as these:

• A letter to the physician when a enrollee has been

identified for the home visit program (either from

utilization data or from a hospitalization).

• An outreach letter to members to schedule visits (when

telephone attempts fail).

• A reminder letter to members about recommended

action steps or follow-up visits.

• A letter or report to the physician describing home

visits, findings, and recommendations.

D. Educational materials

Many health plans develop educational and informational

materials as part of their home visit programs. Materials for

enrollees can educate them about the home visit program

and how it will help them to address environmental asthma

triggers commonly found in the home. Health plans may

also want to provide similar materials to physicians as part of

their health care provider outreach effort (see Step 6.C).

Plans may also want to distribute to their providers copies of

the National Heart, Lung, and Blood Institute’s Practical

Guide for the Diagnosis and Management of Asthma.10 This

document includes a variety of implementation aids, including

reproducible patient handouts.

E. Enrollee tracking system and reporting

It is imperative to track, and to be able to generate reports

of, the following items as enrollees are deemed eligible for

the home visit program:

• Outreach attempts and status.

• Other correspondence (e.g., letters) with members and

physicians.

• Dates and times of home visits.

• Summaries of visits: topics covered, findings,

recommendations.

• Personal knowledge of disease self-management (from

pre- and post-home visit tests) and acquisition of selfmanagement skills.

• Follow-up needed.

If these items are tracked properly, the forms, letters, and

reports described in Step 8.C can easily be generated to

facilitate communication with members and physicians. It is

especially important to be able to report to the enrollee’s

PCP so that he or she can follow up with the individual.

The PCP will also be able to reinforce during office visits

the concepts that were taught during home visits.

Form relationships or

partnerships with community 

asthma organizations.

Whether home visits are outsourced or made by health plan

staff, it is important for the health plan to be familiar with

community groups and organizations that focus on asthma.

Formal and informal relationships with such groups promote

the sharing of valuable information and the dissemination of

best practices. There may be opportunities for formal

referral relationships or collaboration that will enhance the

home visit program while reducing or offsetting some of the

program costs. Health plans should begin to explore

forming relationships with other organizations during goalsetting (Step 4).

For example, community groups such as the Regional

Asthma Management & Prevention Initiative (RAMP) in

California provide educational materials in various languages

and other types of support. As highlighted in Case Study 5,

Allies Against Asthma coalitions sponsor “community

ambassador” programs in which designated community

members can assist in locating and communicating with

individuals who have asthma. Other community groups may

provide thorough environmental assessments or triggerreducing items free of charge to health plan members in

need of such interventions. Public housing authorities and

tenant advocacy groups can help enrollees in situations

where poor housing conditions aggravate symptoms.

13

9.
In addition to community asthma groups,

health plans may find that schools and

employers can also be helpful partners

who can work with them to build or

strengthen community resources.

Implement the

program and track its

results.

Use the tools and forms described in Step

8 and remember to follow up with the

enrollees’ PCPs. Coordination with

patients’ physicians (e.g., PCPs and

specialists) is key to the success of the

home visit program. After determining

what outcomes to measure (Step 7) and

how to measure them, use the trended

results after 6 months to determine:

• The overall efficacy of the in-home

visit program.

• Areas that could be refined (e.g.,

education on mitigations, guidelines

for determining number of visits).

• Whether the program should be

expanded (especially if it was a pilot

program).

Tracking program outcomes and using

the results to improve the home visit

program will improve the plan’s overall

performance, demonstrate the value of

the program, and build provider and

consumer support.

Consider publishing, or at least

disseminating, the results of the program

analysis. Promoting program results will

demonstrate the value of home visit

programs to health care purchasers. 

It will also improve the medical

community’s overall understanding of the

benefits afforded by asthma home visit

programs.

A Final Note

The steps outlined above are meant to serve

as a general guide for health plans

considering whether to begin an asthma

home visit program. The recommendations

are based on current disease management

principles and the experiences of health

plans that are providing home visits to

enrollees with asthma. To achieve the best

outcomes, however, it is important to tailor

a program to the needs of your

organization and its members. Regardless of

program complexity or structure, the keys

to success are:

• Careful planning.

• Strong outreach.

• Community partnerships.

• Ongoing data collection and

comparison to baseline data.

• Program review.

14

10.

CASE STUDY 5 – LEVERAGING ASTHMA RESOURCES IN THE COMMUNITY

The State of Washington’s Medicaid program sponsors an asthma management program

for fee-for-service Medicaid clients. The asthma management program is operated by a

third party vendor. The home visit program is for enrollees with severe asthma or who

have given an indication that they could benefit from face-to-face, rather than telephonic,

care management. Such indicators may include language barriers, significant complex comorbidities, home safety issues, mental health barriers, difficult socio-economic issues,

and environmental issues. The program includes home visits by field nurses who conduct

comprehensive clinical assessments. If a nurse identifies potential environmental triggers

in the home, he or she may refer the enrollee to the local American Lung Association of

Washington, which conducts free home environmental assessments and provides free

mattress and pillow case covers as needed. Any health plan can also take advantage of

this important referral source, so it is important to become knowledgeable about asthma

resources in the community early in the program development process.
Many available resources provide education on asthma,

asthma disease management, home visits, and related topics.

A few of them are discussed below. 

• Allergy & Asthma Network Mothers of Asthmatics

(www.aanma.org): AANMA is a donation-based nonprofit

organization dedicated to helping people affected by allergies

and asthma through education, advocacy, community

outreach, and research. AANMA provides services to patients

and physicians including education materials for all ages,

monthly award-winning publications, a toll-free help line,

Hispanic outreach, and a Web site (www.breatherville.org/

breatherville.htm) featuring Breatherville, USATM, an online

town where learning about allergies and asthma is a positive

experience.

• Allies Against Asthma: AAA is a national demonstration

project funded by The Robert Wood Johnson Foundation.

The Allies Against Asthma Web site (www.asthma.umich.edu)

is a free resource center for individuals and organizations

interested in community-based programs to address pediatric

asthma, particularly in poor, urban, and minority

communities. The Web site includes a “Resource Bank,”

which contains materials, survey instruments, and other tools

for use in controlling and managing asthma.

• American Academy of Allergy, Asthma, and Immunology

(www.aaaai.org): AAAAI is the largest professional medical

specialty organization representing allergists, clinical

immunologists, allied health professionals, and other

physicians with a special interest in allergies. AAAAI’s Web

site includes informational resources, public education

materials, and a “Just for Kids” section that contains games,

puzzles, and other activities to help children learn about and

manage their asthma.

• American Lung Association (www.lungusa.org): ALA is the

oldest voluntary health organization in the United States. Its

focus is fighting lung disease in all its forms, and it particularly

emphasizes asthma, tobacco control, and environmental

health. ALA’s Web site contains a great deal of general asthma

information as well as links to local ALA offices throughout

the country. 

• America’s Health Insurance Plans (http://www.ahip.org):

AHIP is the national association representing nearly 1,300

member companies providing health insurance coverage to

more than 200 million Americans. Taking on Asthma is a joint

initiative of AHIP and the American Academy of Allergy,

Asthma, and Immunology (see above). Taking on Asthma

offers a resource guide (http://www.takingonasthma.org/

resources.htm) that outlines the evidence-based guidelines for

asthma care and features case studies of effective health plan

programs, including the control of environmental risk factors.

• Asthma and Allergy Foundation of America (www.aafa.org):

AAFA is a patient organization dedicated to “improving the

quality of life for people with asthma and allergies and their

caregivers, through education, advocacy and research.” AAFA

has developed numerous educational materials that are

described and can be ordered on-line from its Resource

Catalog. 

• The Center for Health Care Strategies: CHCS has a guidance

document called Achieving Better Care for Asthma Toolkit

(www.chcs.org/usr_doc/AchievingBetterCareForAsthmaTool

kit.pdf). This guidance offers a structured approach for

addressing quality improvement and a collection of “lessons

learned” by a diverse group of health plans serving Medicaid

members. It is comprehensive and covers many topics in

addition to home visits. It offers practical, realistic approaches

that can help Medicaid plans develop new asthma

management programs or improve existing programs.

• The Centers for Disease Control and Prevention: 

CDC’s National Asthma Control Program

(http://www.cdc.gov/asthma/NACP.htm) conducts

epidemiological studies and provides statistics on the

prevalence and costs of asthma. It also provides information

on effective interventions for asthma control, including

methodology for identification of the interventions, results,

lessons learned, information on the interventions themselves,

a bibliography of reviewed literature, and case studies of

several interventions. Other resources, such as a speaker’s kit

for health care professionals and links to other asthma-related

CDC sites and organizations, are available.

• The National Asthma Education and Prevention Program:

NAEPP was initiated in March 1989 to address the growing

problem of asthma in the U.S. (http://www.nhlbi.nih.gov/

about/naepp/index.htm). NAEPP is administered and

coordinated by the National Heart, Lung, and Blood

Institute of the National Institutes of Health. NAEPP has

state-of-the-art clinical practice guidelines for diagnosing and

managing asthma (http://www.nhlbi.nih.gov/guidelines/

asthma/asthgdln.htm). It provides information on treating

asthma at all severity levels and stresses both clinical and selfmanagement strategies.

• Other materials can also be used to enhance the effectiveness

of a home program. For example, some pharmaceutical

companies make asthma education kits that can be sent to

children and their families; many are very child-friendly and

include tools such as puppets, CD-ROMs, and other

educational materials that help children and their families

better understand the disease while reinforcing good disease

management behaviors.

15

Asthma Resources
For more information on EPA’s national asthma program, 

visit http://www.epa.gov/asthma.

EPA encourages the use of its materials when promoting environmental

risk factor management. 

To access EPA’s materials, visit

http://www.epa.gov/asthma/publications.html.

To order these materials at no cost, call EPA’s Indoor Air Quality

Information Line at 1-800-438-4318.

16

1Centers for Disease Control and Prevention.

(http://www.cdc.gov/nchs/products/pubs/pubd/hestats/asthma/asthma.htm)

2 National Heart, Lung and Blood Institute. Morbidity & Mortality: 2004 Chartbook on

Cardiovascular, Lung and Blood Diseases. (www.nhlbi.nih.gov/resources/docs/04_chtbk.pdf)

3 America’s Health Insurance Plans. 2002 Annual Industry Survey of Health Insurance Plans and

Chartbook Findings. (http://www.ahip.org/content/default.aspx?docid=2244)

4 National Heart, Lung and Blood Institute, National Asthma Education and Prevention Program.

Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. NIH

publication number 97-4051. (www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf)

5 See footnote 4.

6 National Academy of Sciences, Clearing the Air: Asthma and Indoor Air Exposures.

(www.nap.edu/books/0309064961/html)

7 To learn more about actions to manage environmental triggers, consult EPA’s Asthma Home

Environment Checklist at http://www.epa.gov/asthma/pdfs/home_environment_checklist.pdf.

8 Morgan W.J., Crain E.F., et al. Results of a Home-Based Environmental Intervention among

Urban Children with Asthma. New England Journal of Medicine 2004; 351:1068-1080, 

Sept. 9, 2004.

9 Building information, secondhand smoke, pets, consumer products, heating and cooling systems,

bedding and sleeping arrangements, flooring, upholstered furniture and stuffed toys, window

treatments, cooking appliances, moisture control, pest control, and outdoor air pollution.

10 National Heart, Lung and Blood Institute, National Asthma Education and Prevention

Program. Practical Guide for the Diagnosis and Management of Asthma. NIH publication

number 97-4053. (www.nhlbi.nih.gov/health/prof/lung/asthma/practgde/practgde.pdf)
Notes
Notes
The U.S. Environmental Protection Agency would like to

acknowledge the following organizations that shared their

experiences in developing and implementing asthma home

visit programs:

Affinity Health Plan

Children’s Mercy Hospitals and Clinics, Health Management

Department/Asthma

Contra Costa Health Plan

Horizon NJ Health

Neighborhood Health Plan

McKesson Health Solutions

Optima Health Plan

The U.S. Environmental Protection Agency would also like 

to acknowledge the contributions of the following people 

who reviewed drafts of the guidance and provided valuable

comments and insights:

Patricia J. Barta, Centers for Health Care Strategies; 

Jeri E. Bryant, Harvard Pilgrim Health Care; Rita Carreon,

America’s Health Insurance Plans; Caroline Erceg, America’s

Health Insurance Plans; Suzanne M. Gaynor, U.S. Department

of Housing and Urban Development; Geralyn Glenn,

America’s Health Insurance Plans; Kevin Kennedy, Children’s

Mercy Hospitals and Clinics; Anne Kelsey Lamb, Regional

Asthma Management and Prevention Initiative; 

Kara Miller, Ohio Department of Job and Family Services; and

Prentiss Taylor, M.D., Amerigroup Health Plans.

Acknowledgments
Office of Air and Radiation

Indoor Environments Division 

(6609J)

EPA 402-K-05-006

August 2005