Partners Putting Guideline

Into Action

Guidelines Implementation Panel Report for: Expert Panel Report 3—Guidelines for the

Diagnosis and Management of Asthma

g

Partners Putting Guidelines 

Into Action

Guidelines Implementation Panel Report for: Expert Panel Report 3—Guidelines for the

Diagnosis and Management of Asthma

National Asthma Education and Prevention Program 

NIH Publication No. 09-6147

December 2008

Table of Contents

Acknowledgments 1

Preface 3

Introduction 5

Background: How Can We Do Better? 5

Objectives of the GIP Report 5 

Approach to Evidence Review 6

A Call to Action 6

Overview of the GIP Report 7

Convening the Panel 7

Developing the GIP Implementation Plan 7

 Framework for Developing GIP Recommendations 

 and Strategies 7

 Core Themes 7

 Guiding Principles of Patient-Centered Care 10

 Priority Messages 10

 Health Disparities: A Fundamental Issue 10

Framework for Mobilizing Asthma Partners into Action 10

 Crosscutting Strategies 10

 Overarching Implementation Approaches 11

Partnering for Success 11

Evaluating the GIP Implementation Plan 13 

The GIP Implementation Plan: Recommendations and Strategies 15 

Use Inhaled Corticosteroids 18

 Communication 18

 Systems Integration 19

 Patient/Provider Support 19

Use a Written Asthma Action Plan 20

 Communication 20

 Systems Integration 22

 Patient/Provider Support 22

Assess Asthma Severity 23

 Communication 23 

 Systems Integration 24

 Patient/Provider Support 25 

Assess and Monitor Asthma Control 25

 Communication 25

 Systems Integration 27

 Patient/Provider Support 27

Schedule Periodic Visits 29

 Communication 29

 Systems Integration 30

 Patient/Provider Support 31
Control Environmental Exposures 32

Communication 32

Systems Integration 34

Patient/Provider Support 35

Appendices 37

A. Levels of Evidence for EPR-3 Recommendations 38

B. Patient-Centered Care Model 39

C. Health Disparities 42

D. Abbreviations 44

List of Figures

Figure 1. Summary of GIP Priority Messages and the Underlying 

EPR-3 Recommendations* 8

Figure 2. Framework for Developing GIP Recommendations 

and Strategies By Message 9

Figure 3. Mobilizing Asthma Partners Into Action — 

Where Does My Organization Fit? 12

Figure 4. Overview: GIP Report Development Process 14 

Figure 5. Integration of GIP Messages and Strategies for

Dynamic Engagement of Stakeholders and a Comprehensive

Implementation Approach 16

Figure 6. Menu of Implementation Activities —

What Can My Organization Do? 17
Acknowledgments 1

Acknowledgments

NAEPP Guidelines Implementation Panel

The NAEPP is grateful to all the Guidelines Implementation Panel members for meeting the challenge of developing this report with tremendous 

dedication and zeal, and to Dr. Kevin Weiss for his 

outstanding leadership. A special thanks to the 

writing team for their extra effort to prepare this 

report.

Kevin B. Weiss, M.D., M.P.H., M.S., Chair *

American Board of Medical Specialties

Evanston, Illinois

David B. Callahan M.D. *

Centers for Disease Control and Prevention

Atlanta, Georgia

Michelle M. Cloutier, M.D. * 

Connecticut Children’s Medical Center

Hartford, Connecticut

Denise Dougherty, Ph.D.

Agency for Health Care Policy and Research

Rockville, Maryland

Kurtis S. Elward, M.D., M.P.H., F.A.A.F.P. *

Family Medicine of Albemarle

Charlottesville, Virginia

David Greenberg

Centers for Medicare and Medicaid Services

Baltimore, Maryland

Carol Jones, R.N., A.E.-C *

Certified Asthma Educator Consultant

Tucson, Arizona

Thomas J. Kallstrom, F.A.A.R.C., R.R.T., A.E.-C

American Association for Respiratory Care 

Irving, Texas

Jim Krieger, M.D., M.P.H. +

University of Washington

Harborview Medical Center

Seattle, Washington

Marielena Lara, M.D., M.P.H. *

Research and Development Corporation

Santa Monica, California

Padmanbhan “Dan” Mukundan, M.D.

Access Community Health Network

Chicago, Illinois

Judith C. Taylor-Fishwick, M.Sc., AE-C

National Respiratory Training Center

Norfolk, Virginia

Gwendolyn Parker, M.D.

Blue Cross Blue Shield of Michigan

Southfield, Michigan

Gary S. Rachelefsky, M.D. *

David Geffen School of Medicine at UCLA

Los Angeles, California

Lawrence D. Robinson, Jr., M.D.

Drew University Medical School

Long Beach, California

Susan K. Ross R.N., AE-C ++

Minnesota Department of Health

St. Paul, Minnesota 

James W. Stout, M.D., M.P.H., F.A.A.P.

Odessa Brown Children’s Clinic

University of Washington 

Seattle, Washington

The Writing Team: 

* Authors of The GIP Implementation Plan: 

 Recommendations and Strategies

+ Author of appendix, Health Disparities

++ Author of appendix, Patient-Centered Care Model
2 National Asthma Education and Prevention Program Guidelines Implementation Panel Report
Preface

The Guidelines Implementation Panel (GIP) 

Report was developed by a panel convened by the 

National Asthma Education and Prevention Program (NAEPP), coordinated by the National Heart, 

Lung, and Blood Institute (NHLBI) of the National 

Institutes of Health. This 17-member panel was 

selected to represent a wide range of asthma 

guideline end users. Members were selected to 

bring balance and diversity to the GIP report 

development process through sharing their unique 

experiences and varying perspectives. Their charge 

was to identify barriers to implementing the 

clinical practice recommendations of the Expert 

Panel Report 3: Guidelines for the Diagnosis and 

Management of Asthma (EPR-3), particularly 

among primary care providers. The GIP was 

tasked to develop recommendations and strategies 

for overcoming the barriers, thereby improving 

acceptance and utilization of asthma guidelines 

overall.

Major emphases of the GIP Report are to close 

the disparity gap for quality asthma care and to 

promote the principles of patient-centered care 

which includes a medical home for patients and 

their participation with healthcare providers as full 

partners in care. At the heart of the GIP Report 

are six key messages derived from a summary of 

priority issues that was compiled by the asthma 

guidelines Expert Panel and submitted to the 

GIP. These issues were considered to be the 

most likely ones to result in significant impact on 

asthma care processes and outcomes if the broader 

asthma community were to focus its attention and 

resources on them.

Preface 3

The GIP Report was developed under the 

excellent leadership of Dr. Kevin Weiss, Panel 

Chair. The NHLBI is grateful for the tremendous 

dedication of time and outstanding work of all the 

members of the GIP as well as other stakeholder 

groups (patient education and advocacy groups, 

professional societies, voluntary health and government organizations) during various review 

cycles that helped to enhance the utility of this 

document. 

Ultimately, the broad change in clinical practice 

depends on the influence of local primary care 

physicians and other health professionals who 

not only provide state-of-the-art care to their 

patients, but also communicate to their peers the 

importance of doing the same. The NHLBI and 

its partners will forge new initiatives based on 

this document to stimulate adoption of the GIP 

implementation recommendations and strategies 

at all levels, but particularly with primary care 

clinicians at the community level. We ask for the 

assistance of every reader in reaching our ultimate 

goal: improving asthma care and the quality of life 

for every person who has asthma.

Elizabeth G. Nabel, M.D.

Director, National Heart, Lung, and Blood Institute

National Institutes of Health
4 National Asthma Education and Prevention Program Guidelines Implementation Panel Report
Introduction 5

Introduction

Background: How Can We Do Better?

The National Asthma Education and Prevention 

Program (NAEPP) of the National Heart, Lung, 

and Blood Institute (NHLBI) recognizes the value 

of clinical practice guidelines in providing information and guidance on the best and most current 

evidence available to diagnose and manage asthma. 

Expert panels have been convened periodically by 

the NHLBI to conduct a systematic review of the 

scientific literature and to prepare a report that 

provides recommendations for making appropriate 

clinical decisions about asthma care. The third and 

most recent report, Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma 

(EPR-3) was released in August 2007.

The NAEPP further recognizes that in order for 

guidelines to reach their full potential in achieving 

positive patient outcomes, their recommendations 

must be widely accepted and utilized across a wide 

range of people and organizations. These intended 

users include medical professionals, office support 

staff, educators, administrators, policy makers, 

purchasers and payors of healthcare services — 

this includes people working across a range of 

healthcare settings (large and small) in both the 

private and public sectors. 

The ultimate goal of the EPR-3 is to improve the 

quality of care and outcomes of people who have 

asthma. Achieving this goal requires understanding the current evidence regarding effectiveness 

of quality improvement efforts, and finding better 

ways to quickly and effectively translate knowledge 

into practice for both patients and healthcare 

providers. Currently, it is estimated that the 

average amount of time to get research findings 

utilized is 17 years. (Institute of Medicine (IOM) 

Report, Crossing the Quality Chasm: A New 

Health System for the 21st Century, 2001). In 

addition, the level to which new findings are 

incorporated into practice is highly variable. 

To engage the intended users and close gaps 

between the scientific advances summarized in 

the guidelines and their practical application 

in the field, the NAEPP convened a Guidelines 

Implementation Panel (GIP). The GIP was tasked 

with preparing a companion report to the EPR-3, 

aimed at identifying the top 5 to 10 priority clinical 

practice recommendations of the EPR-3, shaping 

key messages around these priorities, and presenting clear and achievable strategies for overcoming 

known barriers to implementing these clinical 

practices. Another aim of the report is to motivate 

healthcare providers and their patients to implement asthma management practices that best align 

with quality asthma care and quality of life for 

people who have asthma. 

Objectives of the GIP Report

This GIP Report has three major objectives.

•	 The first objective is to prioritize for NAEPP

constituents and other intended users the top 

5 to 10 priority messages of the asthma guide

lines. The ultimate purpose is to provide focus, 

coordination, and reinforcement for eventual 

collaborative implementation initiatives. 

•	 The second objective is to develop recommendations to improve guidelines implementation 

and to report strategies to make EPR-3 

more useful. This objective targets asthma 

stakeholders (including primary care providers, 

clinicians, educators, leaders, and policy makers) 

across the full spectrum of intended users, 

including patient advocates as well. The GIP 

Report presents a menu of strategies for acting 

on selected key messages. 

•	 The third objective is to have the GIP Report 

serve as a platform for planning of collaborative 

initiatives, and to define the NAEPP’s role 

within the context of a broader asthma control 

initiative. The initiative will be designed to 
6 National Asthma Education and Prevention Program Guidelines Implementation Panel Report

promote partnerships and leadership among 

NAEPP’s Coordinating Committee members 

and other stakeholders based on the role each 

individual organization wishes to play.

Viewed in this way, the GIP Report provides the 

substance and impetus to collectively focus 

intended users on several important issues of the 

EPR-3, that, if implemented widely, could have 

great impact on improving asthma control. The 

report describes ways to apply valuable lessons 

learned from past guidelines implementation 

efforts. As such, the GIP Report furnishes an 

opportunity and invites participation within the 

greater network of asthma stakeholders to: 1) 

direct or redirect resources toward a coordinated 

approach that focuses efforts on activities most 

likely to succeed; 2) seek ways to pool resources 

and collaborate with partners to extend outreach 

and impact; and, 3) assume leadership and a more 

prominent role within the asthma community for 

improving guidelines implementation. 

This report is not an official regulatory document 

of any Government agency. It will be used as the 

platform to implement a national asthma control 

initiative.

Approach to Evidence Review. 

Successful implementation of the asthma guidelines can reduce morbidity and improve the quality 

of life for people who have asthma as well as promote efficiencies and economies of scale for healthcare providers. The EPR-3 used an evidence-based 

approach to enhance acceptability by the widest 

range of intended users. Moreover, the guidelines 

synthesize the scientific evidence published in the 

last 10 years on a comprehensive range of topics 

related to asthma diagnosis and management. 

The guidelines then present conclusions and 

recommendations for clinical practice based on 

this systematic review. 

Several of the research protocols cited and described in the EPR-3 have tested the outcomes of 

specific interventions to improve adoption and 

implementation of guidelines. Examples include: 

communicating medical treatments to patients; 

initiating systems changes for delivery of care; and 

defining and incorporating core components of 

patient/provider education programs, tools, and 

techniques into routine care. Rather than conduct 

its own systematic review of asthma guidelines 

implementation research, the GIP used the 

evidence cited in the EPR-3 and some information from an Agency for Healthcare Research and 

Quality analysis of patient education and quality 

improvement programs in asthma, Closing the 

Quality Gap: A Critical Analysis of Quality 

Improvement Strategies, 2007 (Volume 5—

Asthma). Where the research was not robust, 

the GIP drew upon its professional expertise. 

Furthermore, in instances where a recommended 

implementation strategy has a paucity of literature 

to fully inform its use, the GIP Report may suggest 

that a focus group or brief scan of newly published 

literature be conducted to gather additional knowledge prior to implementation. The objective of the 

GIP Report was to apply what is already known 

and widely accepted from the published body of 

literature on guidelines implementation. 

A Call to Action. 

The immediate challenges ahead for improving 

asthma guidelines utilization are to convert what 

we know from guidelines’ implementation, 

quality improvement, and health care systems 

research into useful tools, processes and pathways; 

to incorporate these resources into a system of 

quality care for patients; and, to build synergy for 

quality care delivery among asthma stakeholders. 

Quality asthma care must be readily and effectively 

delivered by healthcare practitioners and educators 

and augmented and reinforced by other stakeholders in the community. We invite you, as a committed asthma care clinician, community practitioner, 

educator, or decisionmaker, to review this report 

and assist in the larger effort of advancing asthma 

guidelines implementation and better ensuring 

asthma control for people who have asthma.
Overview of the GIP Report 7

Overview of the GIP Report

Convening the Panel. 

In October 2005 the NAEPP appointed a Guidelines Implementation Panel (GIP). Members of

the GIP were selected to represent a balanced yet 

diverse perspective of asthma stakeholders. An 

important charge to the GIP was to develop an 

Implementation Plan consisting of recommendations and strategies designed to identify and 

overcome barriers to implementing the EPR-3 

clinical practice recommendations. 

Developing the GIP Implementation Plan. 

The GIP coordinated preparation of its Implementation Plan with the work of the Expert Panel by 

selecting six priority messages from the EPR-3 

to provide a focus for future implementation 

efforts. To prepare the report’s recommendations

and strategies, these six top-line messages are

integrated with three core themes—communication, systems integration, and patient-provider

support. The six priority messages selected were

deemed to have sufficient leveraging power to 

positively impact patient outcomes. The three

themes were identified by the GIP as being 

associated with successful healthcare interventions. 

Figure 1 lists the six priority messages 

accompanied by the specific EPR-3 clinical 

practice recommendation underlying each 

message. The level of evidence for each of the

EPR-3 clinical practice recommendations is 

also given. A description of the various levels 

of evidence is provided in Appendix A.

The GIP examined each of the six priority messages with respect to the three core themes in order 

to determine target audiences, recommendations,

and strategies for implementing each message. 

The format for presenting the GIP Implementation

Plan follows this outline:

•	 Priority message

•	 Core theme

•	 Target audience

•	 Recommendation

•	 Strategy (including potential key partners)

Framework for Developing GIP Recommendations and Strategies. 

The framework for developing the recommendations and strategies of the GIP Implementation 

Plan is presented in Figure 2. The GIP considered

each of the six priority messages with respect to 

each of the three core themes to develop appropriate recommendations and strategies for selected 

target audiences. The GIP also agreed that a fundamental element—the patient’s perspective—was 

necessary to complete the framework. Thus, they

identified several guiding principles of patientcentered care to serve as a filter for ensuring that 

the patient’s needs and wants would always remain 

top priority. 

The core themes and guiding principles of patientcentered care of the strategy development framework follow.

Core Themes. 

The three core themes identified by the GIP

include:

•	 Communication—getting the messages out on

a broad scale to all audiences, including both

patients and providers, in a variety of settings.

•	 Systems Integration—designing and coordinating messages for essential players up, down, and

across the operational tiers of a given health 

system as well as across multiple health systems; 

and, strengthening linkages between health and

community systems.

•	 Patient/Provider Support—identifying the tools,

techniques and other resources that would 

enhance guidelines implementation.
FIGURE 1

Summary of GIP Priority Messages and the Underlying 

EPR-3 Recommendations*

Message: Inhaled Corticosteroids

Inhaled corticosteriods are the most effective medications 

for long-term management of persistent asthma, and 

should be utilized by patients and clinicians as is recommended in the guidelines for control of asthma.

EPR-3 Recommendation: The Expert Panel

recommends that long-term control medications be 

taken on a long-term basis to achieve and maintain 

control of persistent asthma, and that inhaled 

corticosteroids (ICSs) are the most potent and 

consistently effective long-term control medication 

for asthma. (Evidence A).

Message: Asthma Control

At planned followup visits, asthma patients should 

review level of control with their health care provider 

based on multiple measures of current impairment and 

future risk in order to guide clinician decisions to either 

maintain or adjust therapy.

EPR-3 Recommendation: The Expert Panel 

recommends that every patient who has asthma be 

taught to recognize symptom patterns and/or Peak 

Expiratory Flow (PEF) measures that indicate inadequate asthma control and the need for additional 

therapy (Evidence A), and that control be routinely 

monitored to assess whether the goals of therapy are 

being met – that is, whether impairment and risk are 

reduced (Evidence B).

Message: Asthma Action Plan

All people who have asthma should receive a written 

asthma action plan to guide their self-management 

efforts.

EPR-3 Recommendation: The Expert Panel

recommends that all patients who have asthma be 

provided a written asthma action plan that includes 

instructions for: (1) daily treatment (including medications and environmental controls), and (2) how to 

recognize and handle worsening asthma (Evidence B).

Message: Followup Visits 

Patients who have asthma should be scheduled for 

planned followup visits at periodic intervals in order 

to assess their asthma control and modify treatment 

if needed.

EPR-3 Recommendation: The Expert Panel

recommends that monitoring and follow up is essential (Evidence B), and that the stepwise approach to 

therapy – in which the dose and number of medications and frequency of administration are increased as 

necessary (Evidence A) and decreased when possible 

(Evidence C, D) be used to achieve and maintain 

asthma control.

Message: Asthma Severity

All patients should have an initial severity assessment 

based on measures of current impairment and future risk 

in order to determine type and level of initial therapy 

needed.

EPR-3 Recommendation: The Expert Panel

recommends that once a diagnosis of asthma is made, 

clinicians classify asthma severity using the domains 

of current impairment (Evidence B) and future risk 

(Evidence C, and D*) for guiding decisions in selecting 

initial therapy.

*Note: While there is not strong evidence from clinical 

trials for determining therapy based on the domain of 

future risk, the Expert Panel considers that this is an important domain for clinicians to consider due to the strong 

association between history of exacerbations and the risk 

for future exacerbations.

Message: Allergen and Irritant Exposure

Control

Clinicians should review each patient’s exposure to 

allergens and irritants and provide a multipronged 

strategy to reduce exposure to those allergens and 

irritants to which a patient is sensitive and exposed, 

i.e., that make the patient’s asthma worse.

EPR-3 Recommendation: The Expert Panel 

recommends that patients who have asthma at any 

level of severity be queried about exposure to 

inhalant allergens, particularly indoor inhalant 

allergens (Evidence A), tobacco smoke and other 

irritants (Evidence C), and be advised as to their 

potential effect on the patient’s asthma. The Expert 

Panel recommends that allergen avoidance requires 

a multifaceted, comprehensive approach that focuses 

on the allergens and irritants to which the patient is 

senstitive and exposed -- individual steps alone are 

generally ineffective (Evidence A).

* At least one GIP priority message was selected to correlate with each of the four components of asthma care of the EPR-3:

1) Medications Inhaled Corticosteroids

2) Education for a Patient/Provider Partnership Asthma Action Plan

3) Assessment and Monitoring Asthma Severity

 Asthma Control

 Followup Visits

4) Control of Environmental Factors Allergen and Irritant Exposure Control

8 National Asthma Education and Prevention Program Guidelines Implementation Panel Report
Overview of the GIP Report 9

FIGURE 2

Framework for Developing GIP Recommendations 

and Strategies By Message Key Messages: • Use Inhaled Corticosteriods. • Use Asthma Action Plans. • Assess Severity. • Assess Control. • Schedule Followup Visits. • Control Environmental Exposures. Communication • Target groups

Systems Intergration• Target groupsPatient/Provider Support• Target groups

Patients and Families:Knowledge/Skill

Health Systems:Providers/Technology

Environmental:Economic/ImmediateSurroundings

Influencing Factors

Patient-Centered Care

Core Themes

Recommendations and 

Strategies

Text version
10 National Asthma Education and Prevention Program Guidelines Implementation Panel Report

Guiding Principles of Patient—Centered Care. 

The guiding principles of patient-centered care

identified by the GIP are as follows:

•	 Patient Knowledge and Skills—ensuring access 

to basic health information presented in the 

patient’s primary language and at an appropriate literacy level, and access to educational

opportunities for developing appropriate selfmanagement skills; encouraging and supporting 

a sense of responsibility for, confidence in, and

importance of active participation in one’s own 

health care.

•	 Healthcare Delivery Systems—ensuring 

access to safe, effective care; promoting cultural

competency of healthcare providers and 

performance measures that are tied to positive 

patient outcomes; utilizing up-to-date technology for patient/provider education and clinical 

information systems; and, encouraging each

patient who has asthma to have a medical home.

•	 Community Systems—acknowledging the

immediate environment as exerting important 

influence over health (e.g., home, workplace,

school, etc.); acknowledging ambulatory and

community-based services as preferable to 

institutional care when clinically appropriate; 

identifying valuable community resources to 

augment health care and to address the social 

and financial needs of patients; referring 

patients to agencies and services outside of 

the clinical setting.

A full description of the Patient-Centered Care 

Model can be found in Appendix B.

Priority Messages. 

The six priority messages were initially derived

from a summary of overall EPR-3 priority issues 

prepared by the Expert Panel to address each of 

the four essential components of asthma care. 

GIP members developed an initial list of 22 

potential messages from the Expert Panel’s priority 

issues summary. GIP members selected the 

six priority messages from the initial list of 22 

based on the criteria of: strength of evidence as 

provided in EPR-3 for the guidelines recommendation underlying each message; and, feasibility of

implementing the message. At least one priority 

message was selected to correlate with each of the 

four components of asthma care (see Figure 1). 

The six selected priority messages were considered

to be most likely to produce a significant impact on 

asthma care processes and outcomes if the asthma 

community were to focus attention and resources 

on active implementation.

Health Disparities: A Fundamental Issue. 

A fundamental issue to address in the context 

of all six messages is the reduction of asthma 

disparities. The burden of asthma is not uniform

across all populations. People of racial and ethnic 

minorities and those of low socioeconomic 

status are disproportionately affected. Asthma 

prevalence is 25 percent higher among American 

Indian or Alaska Native children, 60 percent higher

among African American children, and 140 percent

higher among Puerto Rican children relative to 

White children. African American children have 

a 260 percent higher emergency department (ED)

visit rate and a 250 percent higher hospitalization 

rate from asthma compared to White children. 

Access to medical care for asthma and the 

quality of care provided is often lower among the 

minority and socioeconomically disadvantaged 

populations. Exposure to environmental factors 

that worsen asthma is also more frequent. These

disparities in asthma burden and care suggest 

that culturally competent clinical and educational 

approaches are needed to implement the EPR-3 

guidelines in high-risk groups.

A summary paper highlighting important issues 

affecting access to, and quality of, healthcare services among disparate populations was developed 

(see Appendix C). The purpose was to inform GIP

discussions to better ensure that these important 

issues were addressed in the final recommendations and strategies for the six priority messages.

Framework for Mobilizing Asthma 

Partners into Action. 

Crosscutting Strategies. 

To facilitate navigation through the volume and

variety of implementation strategies generated 

across all six messages, the GIP identified several

crosscutting activities any one of which can be 

integrated across multiple messages to form 

one comprehensive intervention. Listing these 

crosscutting activities is intended to provide stakeholders with a short-hand view of the nature and 

range of GIP recommendations, thereby helping

them more quickly assess which strategies best 

align with the activities of their organization. 
Overview of the GIP Report 11

The crosscutting activities include:

•	 Providing asthma self-management education

to patients, their families, and their caregivers

•	 Providing clinical practice and communication

skills-building education to clinicians and 

ancillary healthcare professionals

•	 Employing quality improvement strategies

•	 Supporting structures for asthma care financing

•	 Building new and utilizing existing communication networks 

Overarching Implementation Approaches. 

Furthermore, the GIP identified three overarching

approaches to effect implementation of the recommendations and strategies. These overarching

approaches are intended to offer the utility needed 

to organize and coordinate efforts in carrying out 

the GIP Implementation Plan on a broad scale. 

The overarching approaches are to:

•	 Stimulate and coordinate NAEPP initiatives,

partnerships, and collaborative activities

to facilitate implementation of the GIP 

Implementation Plan.

•	 Develop, implement, and evaluate a coordinated

national asthma campaign to educate the public,

patients, caregivers, healthcare practitioners,

educators, employers, and administrators

about the 6 priority messages of the EPR-3 as 

identified in the GIP Implementation Plan. 

•	 Convene a national asthma policy forum to

include entities such as commercial and public 

health plans, professional associations, experts

in performance measurement, public and

private healthcare financing organizations,

patient advocacy groups, employers, workplace

advocacy groups, state and local policy

makers, environmental, school, and other

national, state and local agencies. The forum

would feature expertise in public health and 

health policy and promote the implementation 

of policies that advance the asthma 

guideline implementation initiative.

How well these overarching approaches align with 

an organization’s mission, goals, and resources will

help an organization determine where it best fits in 

the larger scheme of the GIP Implementation Plan.

The crosscutting activities paired with the overarching approaches form a conceptual framework 

that is useful in identifying appropriate and 

willing partners to help operationalize the GIP 

Implementation Plan. See Figure 3, Mobilizing

Asthma Partners Into Action—Where Does My 

Organization Fit?

Partnering for Success. 

The asthma community has a diverse, dedicated

and active group of stakeholders. A successful 

initiative for improving asthma control will 

require their broad participation, engagement and

collaboration. Many potential partners are identified in the proposed strategies of the GIP Implementation Plan that follows. They include but are

not limited to:

•	 Patients and their families

•	 Patient education and advocacy groups

•	 Clinicians and educators of various disciplines

—doctors (primary care and specialists), nurses

and nurse practitioners, respiratory therapists,

pharmacists, physicians’ assistants, asthma

educators

•	 Professional associations

•	 Provider education groups

•	 Health care administrators and managers

•	 National accrediting agencies

•	 Hospitals and emergency departments

•	 Government health service agencies and

programs

•	 Managed care organizations

•	 Commercial health plans and payors

•	 Experts in performance measurement

•	 Electronic Health Record companies

•	 State and local government agencies

•	 Schools/childcare centers, students and staff

•	 Community-based organizations—community

centers, faith-based organizations

•	 Local asthma coalitions—peer educators,

community health workers, public health

doctors, nurses and other healthcare disciplines,

epidemiologists and others engaged in population studies 

•	 Academic centers, medical schools and training

programs

•	 Media writers and editors

•	 Worksites, employees, health benefits managers,

worker advocacy groups

•	 Private foundations, local businesses, corporations, pharmaceutical industry

It is important for these many partners to work 

together. Thus, in the spirit of collaboration,

highlights from a draft of the GIP Report were 

presented at a meeting of the NAEPP Coordinating 

Committee and other asthma stakeholders 
12 National Asthma Education and Prevention Program Guidelines Implementation Panel Report

FIGURE 3

Mobilizing Asthma Partners Into Action — 

Where Does My Organization Fit? Overarching Approaches

Crosscutting Activities

Patient SelfManagementEducation

Provider SkillsBuilding

QualityImprovement

FinancingSupportStructures

CommunicationNetworks

NAEPP Initiatives/Partnerships

National Asthma Campaign

National Policy Forum

Recommendations and 

Strategies

Text version
Overview of the GIP Report 13

in October 2007. The report is intended to

serve as a roadmap for prioritizing and initiating 

future NAEPP activities, and for identifying

and cementing partnerships among various 

stakeholders who express interest in taking the 

lead on various sections of the GIP Implementation Plan. Sharing highlights was an effort to get 

the momentum started before final release of 

the report. The NAEPP will take the lead to

implement a large-scale coordinated National 

Asthma Control Initiative and engage a broad 

stakeholder base in collaborative implementation 

activities.

Evaluating the GIP Implementation Plan. 

An overall evaluation and communication 

framework will be developed by the NHLBI with 

input from its partners. Partners who undertake 

implementation of the GIP strategies will be 

encouraged to formulate metrics for measuring 

their outcomes based on the framework. An 

NHLBI Web-based Pulmonary Knowledge

Network has been proposed as an active system 

to monitor activities and facilitate coordination 

and communication among partners regarding 

progress on, and evaluation of, their guidelines

implementation activities.

Figure 4 provides a graphic summary of the 

GIP Report development process and how the 

implementation phase is shaped to engage partners 

as active participants to help in the implementation of the GIP recommendations and strategies 

and thereby improve asthma control. 
14 National Asthma Education and Prevention Program Guidelines Implementation Panel Report

FIGURE 4

Overview: GIP Report Development Process

Six Priority

Messages

Scientific Evidence

Patient-Centered Care

Communication Patient/Provider Supports

Health and Community

Systems Intergration

Recommendations Recommendations Recommendations 

Partner

Engagement

Strategies Strategies Strategies
The GIP Implementation Plan: Recommendations and Strategies 15

The GIP Implementation Plan:

 Recommendations and Strategies

Once the framework for developing recommendations and strategies was established, (see Figure 2) 

the GIP writing team began filling in the details. 

Writers first identified priority target audiences for 

each strategy and then several likely key partners 

for carrying out the strategy. 

The GIP acknowledges that the ultimate target 

group intended to benefit from improved 

guidelines implementation is people who have 

asthma, particularly those at high risk. However, 

the recommendations and strategies proposed by 

the GIP are mostly targeted at intended users of 

the guidelines who are viewed not only as the 

adopters, but also as agents of change, i.e., the 

asthma stakeholders to be depended on for 

instituting the desired changes aimed at benefiting patients. As such, an identified target group 

is often also a key partner to help in planning and 

implementing the strategy. The GIP Implementation Plan does not attempt to specifically assign 

who should initiate and/or participate in implementing a particular strategy, but rather suggests 

a few traditional and likely partners for each. 

The plan invites and encourages all organizations 

to examine their organization’s mission, goals, and 

resources to decide if, and what role, they wish 

to play (see Figure 3). 

The GIP Implementation Plan is presented on 

the following pages by each of the six selected 

priority messages. Some stakeholders may choose 

to focus on just one message and one strategy to 

promote that message; others may choose to focus 

on multiple strategies to promote a single message. 

Still other stakeholders may take a more comprehensive approach and choose to focus on more 

than one message (maybe all six) using one or 

more strategies. Each stakeholder and stakeholder 

organization will determine the desired extent of 

their engagement. Figure 5 offers a graphic 

representation of how an organization may 

choose to implement one or multiple messages 

using either a single strategy or several strategies. 

A generalized list of strategies that could apply 

equally to the implementation of any of the six 

messages is provided. Figure 6 expands the 

generalized list of strategies to provide a dropdown menu of specific activities for each 

strategy. Organizations can use this menu as a 

quick reference to help determine which activities 

are compatible with what they are currently doing 

and/or that can easily be fit into the scope of their 

work. Or, organizations can use this menu to plan 

future activities that can be phased in. The desired 

outcome is for each stakeholder organization to 

find its own niche, but for the collective efforts 

of multiple organizations to cover the full gamut 

of messages and strategies—thus providing the 

framework for a comprehensive National Asthma 

Control Initiative (NACI).

Message: USE INHALED CORTICOSTERIODS. 

Inhaled corticosteroids are the most effective 

medications for long-term management of 

persistent asthma and should be utilized by patients and clinicians as is recommended in 

the guidelines for control of asthma.

Inhaled corticosteroids (ICS) are the most 

consistently effective, long-term control 

medications for persistent asthma. They are 

the preferred therapy for initiating long-term 

control medications. However, alternative options 

for medications are available to tailor treatment 

to individual patient circumstances, needs, and 

preferences; options and their appropriate use are 

presented in the EPR-3. Generally, ICSs improve 

asthma control more effectively, in both children 

and adults, than any other single long-term control 

medication. The benefits of ICS outweigh the 

concerns about the potential risk of a small, 

non-progressive reduction in growth velocity in 

children, or other possible adverse effects.
16 National Asthma Education and Prevention Program Guidelines Implementation Panel Report

FIGURE 5

Integration of GIP Messages and Strategies for Dynamic Engagement 

of Stakeholders and a Comprehensive Implementation Approach 

Organization 1

Organization 2

Organization 3

Organization 4

Organization 5

Organization 6

6 Messages

5 Messages

4 Messages

3 Messages

2 Messages

1 Message

Partner Engagements: Reach: ICS AAP Severity Control Visits Environment

Six Priority

Messages

Provide patient self-management

Promote financing support structures.

Strengthen linkage between medical and 

community-based resources

Collate, analyze and share data

Disseminate and market the national Asthma Control

Initiative activities, result and products.

Gather information with repsect to 

message barriers/solutions for 

indentified priority audiences.

Convene knowledge brokers, influence

leaders and decision-makers.

Pilot test strategies.

Provide professional education and training.

Provide point-of-services prompting.

Conduct Quality Improvement (QI).

Strategies to disseminate messages:

Key: ICS = Inhaled Corticosteriods

AAP = Asthma Action Plan
The GIP Implementation Plan: Recommendations and Strategies 17

FIGURE 6

Menu of Implementation Activities —

What Can My Organization Do?

n Gather information with respect to message barriers/ 

solutions for identified priority audiences.

• literature review

• focus groups

• leader interviews

• surveys

n Provide patient self-management education.

• educational materials

• materials adaptation – e.g. cultural, literacy, 

 language

• counseling – e.g., clinic, peer

• group education

• skills training – e.g., devices, empowerment

• home visits

n Convene knowledge brokers, influential leaders and 

decisionmakers.

• resource development

• model policies

• model benefits package

• core element criteria – e.g., education tools, 

patient encounter forms, key clinical activities

• basic quality care criteria

• sample templates – e.g., action plans, clinical 

 pathways

• uniform measures – e.g., performance, outcomes

• procedural guides – e.g., allergy testing, 

 spirometry

n Promote financing support structures.

• developing a business case

• reimbursement for education

• basic quality care criteria

• relevant CPT codes

n Pilot test strategies.

• demonstration projects

• clinical networks

n Strengthen linkages between medical and communitybased resources.

• engage local coalitions

 • engage pharmacies

• engage schools and child care centers

• engage workplaces

n Provide professional education and training.

• recertification training modules

• academic detailing

• problem-based/ skills development 

 programs -- CMEs

• medical/nursing school curricula

• tool kits

n Provide point-of-service prompting.

• electronic health record

• visit encounter checklist/documentation notes

• pocket guides

• Personal digital assistant

• standing orders

• sample templates

n Conduct Quality Improvement (QI).

• provider feedback

• incentives

• plan-level quality measures

• QI collaboratives

• recertification QI modules

n Collate, analyze and share data.

• monitor, evaluate and report progress for 

intervention projects

• monitor, evaluate and report adherence to 

guidelines – patients and providers

• monitor, evaluate and report patient outcomes

n Disseminate and market the National Asthma Control 

Initiative activities, results and products.

• website

• newsletters

• meetings/events

• email alerts
18 National Asthma Education and Prevention Program Guidelines Implementation Panel Report

Communication

Rationale: Communicating the effectiveness, safety 

and importance of ICSs for asthma control and 

addressing concerns about their long-term use 

should occur at all levels of health care. It is also 

important for clinicians and educators to tailor 

their communications based on consideration of 

the patient’s health literacy level; and, to develop 

a heightened awareness of health disparities and 

cultural barriers that facilitate more effective 

communication with minority (ethnic or racial) 

or economically disadvantaged patients regarding 

the use of asthma medications that may improve 

asthma outcomes. Patient-provider communication about ICS needs reinforcement and support 

throughout the healthcare system.

Patients and Their Families

Recommendation: Determine the most appropriate 

methods for teaching patients from diverse populations about the role of ICS in long-term asthma 

management.

Strategy 1: Through collaboration with 

stakeholders such as patient advocacy and 

educational groups and professional associations, refer to EPR-3 and search other 

recent literature to identify known barriers 

to conveying the ICS message to patients and 

their families. Scan for tested strategies and 

methods that have been shown to overcome 

these barriers.

Strategy 2: Within the context of social marketing and health communications techniques, 

use results of the scan to develop messages and 

media outreach activities that are tailored to the 

languages, literacy and health beliefs of intended audiences. Engage patients from the target 

group, as well as academic and commercial 

or marketing entities in this process. Pilot 

test the messages using patient focus groups 

and disseminate the final messages through 

various patient education channels, professional 

associations, media outlets, and partner 

engagement activities.

Prescribing Clinicians

Recommendation: Develop and deliver messages 

that enhance clinicians’ understanding and 

willingness to prescribe ICS.

Strategy 1: Enlist the support of professional 

associations, specialty boards and provider 

education groups to develop multidimensional, 

interactive and practice-based continuing 

medical education (ME) and maintenance of 

certification (MOC) materials that convey 

the importance of ICS in the management of 

persistent asthma. 

Strategy 2: Collaborate with stakeholders involved in creative marketing solutions, purveyors of health education Web sites and others 

who bring health communication expertise 

in developing concise and effective messages 

aimed at clinicians that promote the appropriate use of ICS, and that also resonate with other 

members of the healthcare team.

Strategy 3: Identify and/or develop model 

standing orders for patients on the use of ICS 

for persistent asthma and encourage asthma 

educators to inform patients about the orders. 

Also, disseminate these orders to physicians 

and others on the healthcare team to simplify 

prescribing ICS.

Payors and Pharmacy Benefits Managers

Recommendation: Garner interest and commitment among payors and pharmacy benefit 

managers (PBM) to play a major role in 

communicating messages about the effectiveness 

of using ICS for asthma control in patients who 

have persistent asthma; and, in recommending ICS 

use to health benefits purchasers as a cost-effective 

approach for achieving positive patient outcomes.

Strategy 1: In collaboration with health insurance organizations, such as America’s Health 

Insurance Plans (AHIP) and Blue Cross Blue 

Shield Association (BCBSA), request that a 

group of payors/PBMs develop an effective 

approach to communicate the EPR-3 

recommendations on the use of ICS.

Strategy 2: Consult with major purchasers of 

health benefits (i.e., large employers) and health 

actuaries to assist with developing messages 

that address the costs of effective asthma 

management and the relative costs of providing 

ICS with respect to patient outcomes. 
The GIP Implementation Plan: Recommendations and Strategies 19

Strategy 3: Work with health plans, payors and 

PBMs to develop an optimal formulary with 

standardized beneficial design for dissemination as a template. 

System Integration

Rationale: Promoting appropriate use of ICS 

throughout the healthcare system supported by 

improved coding for asthma severity (see Systems 

Integration, Payors and Purchasers under Severity message) will reinforce efforts for use of ICS by 

patients and their providers, helping to eliminate 

barriers to their use at the system level. 

National Accrediting Agencies

Recommendation: Develop and implement a new 

Healthcare Effectiveness Data and Information Set 

(HEDIS) measure that encourages the use of ICS in 

the management of persistent asthma.

Strategy 1: Convene a meeting and provide 

support to a National Committee on Quality 

Assurance (NCQA) working group to determine measurable outcomes of ICS use with an 

emphasis on continued use over the long term.

Strategy 2: Network with managed care 

organizations (MCOs) to develop broad support for a HEDIS measure for ICS use.

Government Health Service Agencies

Recommendation: Develop and implement 

policies and programs supporting the use of ICS 

in the management of persistent asthma.

Strategy 1: Engage relevant groups, e.g., clinical 

care advisory committees, medical certification 

and drug utilization review boards in the 

development of quality measures and payfor-performance schema that include the 

appropriate use of ICS.

Strategy 2: In conjunction with such constituency groups as the State Medicaid Medical 

Directors, explore ways to identify and disseminate information on State initiatives that 

encourage the use of ICS, such as incentive 

programs and reimbursement schemes. Make 

States aware of evidence-based guidelines and 

innovative approaches to addressing common 

problems such as availability and prescribing of 

appropriate medications.

Medical Practice Oversight Groups

Recommendation: Identify and/or develop and 

distribute model policies for large medical practice 

oversight groups that support the use of ICS for 

patients with persistent, or not well-controlled, 

asthma.

Strategy 1: In conjunction with the American 

Medical Group Association (AMGA), convene 

a meeting of physician managers, medical 

group executives and clinic physicians to discuss and develop a model policy for ICS use.

Strategy 2: Through AMGA and its affiliated 

organizations, encourage the adoption of a 

model policy and provide consultation on its 

implementation to member medical groups.

Patient/Provider Support

Rationale: Asthma patients who understand the 

need for ICSs might still face barriers to their use. 

Methods, resources and systems that promote the 

ready availability and easy use of ICSs and of their 

delivery devices (e.g. spacers or holding chambers) 

should be accessible to patients and providers.

Patients and Their Families

Recommendation: Identify and reduce the barriers 

to ICS use among patients and their families.

Strategy 1: Through collaboration with stakeholders such as patient advocacy organizations, 

patient education groups and professional associations, review EPR-3 and existing literature 

on patients’ reasons for consistently using or 

not using ICS daily therapy. Identify the main 

barriers to using ICS including, but not limited 

to, a lack of appreciation for the chronic nature 

of asthma and the need for daily therapy, misconceptions of the healthcare system, and lack 

of educational materials that are culturally and 

linguistically appropriate.

Strategy 2: Through the collaboration of 

professional associations, provider- and 

patient-education groups, address the identified 

barriers by promoting use of existing methods 

and resources and, if necessary, developing 

additional ones that encourage the consistent 

use of ICS. Work with patient education advocacy groups and professional associations to 

disseminate the resources. 
20 National Asthma Education and Prevention Program Guidelines Implementation Panel Report

Professional Associations

Recommendation: Eliminate barriers to physicians 

and other clinicians to appropriately prescribe ICS 

and encourage the use of ICS for persistent asthma.

Strategy 1: Convene a panel of formally 

trained asthma educators in collaboration with 

physicians, clinicians and midlevel providers 

to collect, review and develop point-of-contact 

methods and materials designed to enhance the 

use of ICS. Such could include patient reminders, electronic health record (EHR) clinical 

pathways, and tailored patient educational 

materials.

Strategy 2: Work collaboratively with professional associations and state asthma coalitions 

to disseminate these products through existing 

member networks using the most effective 

approaches.

Strategy 3: In collaboration with EHR vendors 

and informatics experts develop and distribute 

a clinical pathway template for asthma management that includes prompts to communicate 

and encourage appropriate use of ICS and 

standardized data collection elements that 

support evaluation of implementation activities 

and related practice-based research studies.

Patient Advocacy Groups

Recommendation: Develop messages and resources 

that will empower patients to seek and maintain 

treatment with ICS for long-term management of 

persistent asthma.

Strategy 1: Forge strong alliances among 

patient advocacy and education groups in 

collaboration with professional associations 

and other stakeholders. Through this alliance 

convene a virtual meeting of patient newsletter 

editors to collect and review existing materials 

for wider dissemination and, where appropriate, develop new content aimed at educating 

and empowering patients on interactions with 

their healthcare providers. Provide this information to editors of local chapters of advocacy 

groups.

Strategy 2: Through community organizations, 

the local medical community and professional 

associations, identify and/or develop presentation material to support a speaker’s bureau of 

clinicians, educators, patients, and family members who are available for meetings and public 

events to convey and reinforce the message of 

appropriate ICS use.

Strategy 3: Utilize a targeted national asthma 

campaign and social marketing initiative that 

includes the NAEPP and its partnering organizations to promote the six GIP messages, 

including the message on the importance of 

ICS for persistent or poorly controlled asthma 

as well as its safety and effectiveness in ongoing 

asthma management. 

Message: USE WRITTEN ASTHMA ACTION PLANS.

All people with asthma should receive a written 

asthma action plan to guide their self-management efforts.

Many patients have difficulty recalling instructions 

for care that are given by their healthcare 

provider. A written asthma action plan (AAP) 

provides instruction and information on how to 

self-manage one’s asthma daily, including taking 

medications appropriately, and identifying and 

avoiding exposure to allergens and irritants that 

can bring about asthma symptoms. In addition, 

the AAP provides information on how to 

recognize and handle worsening asthma, and 

when, how and who to contact in an emergency.

Communication

Rationale: To improve communication, AAPs 

need to be written clearly and implemented on 

many levels. First and foremost, clinicians should 

be able to choose a format for patient instruction 

that is consistent with their practice and their patient’s needs. At the same time, however, clinicians 

should not have to create these plans anew. For 

children, these plans should be made simple and 

easy for schools, school nurses, and school-based 

health centers to use. Schools play a significant 

role in reinforcing use of a child’s written AAP. In 

addition, AAPs should be easy for patients and 

their families to understand and presented in a 

format that encourages self-management. AAPs 

serve as the vehicle of coordination across multiple 

caregivers and as a linking mechanism between 

community and clinical sites. Communicating the 

policies that guide use of AAPs at various points of 

care will reinforce their use.
The GIP Implementation Plan: Recommendations and Strategies 21

Prescribing Clinicians

Recommendation: Provide templates for written AAPs that include the core elements of action 

plans described in EPR-3, and that offer choices 

by age or setting (schools, workplace, childcare 

centers) and that are clear and easy to use. This set 

of sample templates will facilitate a standardized 

approach to developing an AAP for patients and 

ease of use by clinicians, thereby increasing his/her 

willingness to use it. 

Strategy 1: Enlist the support of professional 

associations, clinicians and patient- and provider-education groups to review existing AAPs; 

and, as necessary, develop national prototypes 

of written AAPs that are simple, clearly understood, and easily tailored to meet the needs of 

diverse ethnic populations and patients.

Strategy 2: Obtain buy-in from primary care 

and medical specialty associations to support 

the production and dissemination of the prototype AAPs to clinicians.

Patients and Their Families

Recommendation: Identify patient and family 

needs and preferences regarding the content and 

format of written AAPs. Identify best ways to 

communicate with patients on the importance of 

action plans and how to ask their healthcare provider for them. 

Strategy 1: Through patient advocacy groups 

and professional associations, gather information from the EPR-3 and other credible sources 

to identify and summarize messages and 

instructions that patients and families need to 

better manage their asthma.

Strategy 2: Collect and disseminate AAP 

templates that provide inclusion of the recommended core elements of an action plan as 

presented in EPR-3. 

Strategy 3: Develop and promote the use of 

action plans that are culturally, educationally 

and linguistically meaningful to a diverse group 

of patients and their families. Coordinate this 

effort to reach patients with an outreach approach to healthcare providers (see Strategy 1 

for Prescribing Clinicians, noted above).

Strategy 4: Work with patient advocacy and 

education organizations to encourage patients 

to ask their providers for an individualized 

AAP, or teach patients how to obtain a sample 

plan to take to their provider to develop an 

individualized AAP.

Schools, School Nurses, and School-Based Health 

Centers and Childcare Centers

Recommendation: Make available to schools, 

school nurses and/or school- based health centers 

or childcare centers, prototypes of the written 

AAPs that can be used for each student who 

has asthma. 

Strategy 1: In collaboration with the NAEPP 

and its School Asthma Education Subcommittee convene a working group with representation from primary healthcare providers (family 

medicine, pediatrics and nursing), specialty 

associations, state-level health and education 

agencies, school boards, and school administrator organizations to identify and, if appropriate, develop a model policy and methods for 

implementing AAPs and facilitating communication and the sharing of written AAPs between 

primary care clinicians’ offices and schools for 

the purpose of coordinating care. Also, identify 

and encourage the acceptance and use of standardized AAPs by school districts.

Strategy 2: In collaboration with professional associations, asthma educators, school 

educators, and nurses, identify existing and/

or develop and implement a new educational 

program or workshop that addresses the use of 

AAPs for school personnel. This will enhance 

the education and skills of school staff, school 

nurses, and school-based health center staff in 

recognizing and managing asthma based on 

written AAPs and in understanding the policy 

issues related to AAPs.

Strategy 3: In collaboration with the NAEPP 

and its School Asthma Education Subcommittee, develop an enhanced Web page, or “community of practice” web site, that summarizes 

and makes accessible in one place school 

asthma information and resources, and that 

invites visitors to participate in a series of featured venues. Market the web page widely to 

participants who share in its common purpose 

and who will benefit from it.
22 National Asthma Education and Prevention Program Guidelines Implementation Panel Report

Systems Integration

Rationale: Policies and programs that create 

accountability will better ensure the use of an 

AAP. Furthermore, EHRs that include written 

AAP will encourage and reinforce provider use. 

Personal Health Records, intended for use by the 

patient can support self-management of chronic 

conditions such as asthma.

Government Health Services Agencies 

Recommendation: Engage decisionmakers to 

develop and implement policies and programs 

that promote the use of written AAP as part 

of basic care and coordination of care. 

Strategy 1: Through collaboration of stakeholders working with Centers for Medicare and 

Meicaid Services (CMS), engage State Medicaid 

Medical Directors in a discussion about ways to 

encourage and increase the use of written AAP.

Strategy 2: Utilize a national asthma policy 

forum to facilitate and coordinate efforts that 

encourage leadership within government health 

service agencies to develop policies, quality 

improvements and pay-for-performance 

measures that include the use of written 

AAP for patients who have asthma.

Managed Care Organizations and Healthcare 

Payors

Recommendation: Engage decisionmakers to 

develop and implement policies and programs that 

promote the creation and distribution of written 

AAPs as a basic part of effective asthma care. 

Strategy 1: Through the collaboration of 

(MCOs) and healthcare payors, convene a 

meeting of healthcare payors, benefits managers, key MCO representatives (managers, 

physicians and other prescribing clinicians, and 

medical group executives) to develop a model 

policy for the use of written AAPs.

Strategy 2: Pilot test the model policy, including a method for documenting that an AAP was 

provided (e.g., using an EHR) and a method for 

prompting timely updates of the AAP thus better ensuring compatibility with available medicines and benefits. Documentation will help to 

monitor any associated incentive programs. 

Strategy 3: Utilize a national asthma policy 

forum to facilitate the distribution, and 

encourage the adoption and implementation, 

of a model policy for AAPs that embeds quality 

measures and pay-for-performance measures 

into the policy.

Electronic Health Record Companies

Recommendation: Facilitate the use of written 

AAPs by physicians and other clinicians by integrating plans into EHRs. 

Strategy 1: Using an approach coordinated by 

EHR companies, develop and distribute a comprehensive written AAP that is easily understood by patients and their families; and, that 

is comprised of the core elements of an AAP as 

described in the EPR-3.

Strategy 2: Ascertain and act on ways to gain 

the interest and commitment of EHR companies to promote their module on the use of 

written AAPs for people who have asthma.

Patient/Provider Support

Rationale: The patient’s goals, concerns, beliefs, 

and attitudes should be addressed, as these are keys 

to successful use of AAPs as a self-management 

tool. Sharing in the decisionmaking process with 

their healthcare provider will encourage patients to 

use the AAP. In addition, engaging other members 

on the patient’s healthcare team, and practitioners 

and educators at alternative points of care (i.e., 

schools, pharmacies, etc.) will help to reinforce 

the importance of patient self management using 

an AAP.

Patients, Families and their Clinicians

Recommendation: Identify and reduce the barriers 

to use of written AAPs by patients and their families and create an environment of shared decisionmaking with clinicians. 

Strategy 1: Patient advocacy, education groups 

and professional associations should refer to 

the EPR-3 and other credible sources to identify 

and summarize known barriers for using AAPs 

by patients and their families. This information 

can be used to inform clinicians on approaches 

to use for overcoming these barriers. If needed, 

search additional recent literature for strategies 

and methods that have been tested and shown 

to be effective in overcoming these barriers. 
The GIP Implementation Plan: Recommendations and Strategies 23

Strategy 2: Enlist asthma educators, patient 

advocacy groups, and other healthcare professionals to educate patients on the skills and 

rationale for self management and utilization 

of their AAPs.

Strategy 3: Encourage patient education programs to demonstrate techniques patients can 

use to request written AAPs from their providers and motivate them to use these 

techniques. 

Pharmacists and Other Health-related Providers 

Recommendation: Utilize multiple points-ofservice, in particular pharmacies where patient 

encounters occur, to increase utilization of written 

AAPs. 

Strategy 1: Convene a meeting of pharmacists, 

prescribing clinicians, nurse practitioners, 

asthma educators, and school nurses as well as 

patients and other related disciplines to discuss 

ways to improve dissemination and reinforcement of the use of written AAPs in a variety 

of settings.

Strategy 2: Work with pharmacists and healthcare providers to identify ways to better support 

the use of EHRs for reinforcing a patient’s use 

of his/her written AAP. 

Message: ASSESS ASTHMA SEVERITY. 

All patients should have an initial severity assessment based on measures of current impairment 

and future risk* in order to determine type and 

level of initial therapy needed.

Asthma severity is the intrinsic intensity of the 

asthma disease process and is measured most 

easily and directly in a patient who is not receiving 

long-term control therapy. Information gathered 

in the assessment of asthma severity is used to 

characterize the patient’s asthma in order to guide 

decisions for initiating therapy, after which the 

focus shifts to how well the patient is able to 

control his or her asthma by following the treatment plan. A severity assessment ensures the 

appropriate use of pharmacologic agents. Both 

asthma severity and asthma control are determined 

by the same measures in two domains: 1) current 

impairment, and 2) future risk. Once treatment is 

started, the results of the measures of impairment 

and risk are used to monitor asthma control rather 

than severity. Monitoring the level of asthma 

control is used to adjust medication as needed. 

Communication

Rationale: Clinicians should determine severity of asthma as part of their initial assessment 

of patients who have asthma. Asthma severity 

should be documented in the patient’s record and 

the significance of this assessment explained to 

the patient. Patients should know that regardless 

of severity classification, all asthma is serious and 

requires patients to follow their treatment plans. 

Likewise, patients need to be able to communicate 

information to their healthcare providers about 

their asthma and how it affects their lives. This 

will help the healthcare provider to assess the level 

of impairment and risk for determining a patient’s 

initial asthma severity and treatment requirements. 

Primary Care Providers and Other 

Healthcare Clinicians 

Recommendation: Encourage clinicians to document information in the patient’s record with 

respect to measures of impairment and risk and 

also the resulting level of asthma severity that this 

combination of measures indicates. Encourage 

clinicians to explain to the patient the significance 

of asthma severity at diagnosis in developing an 

initial treatment plan and then how the emphasis 

shifts to monitoring control of asthma over the 

long term using the same measures of impairment 

and risk.

Strategy 1: Encourage collaboration among 

professional associations and other asthma 

stakeholders in setting up a clearinghouse of 

sample tools for assessing severity and initiating therapy accordingly in clinician-friendly 

formats. Develop and execute a plan for 

promoting these resources to primary healthcare providers and asthma specialists, and for 

assessing and explaining severity in different 

populations in a variety of settings. 

Strategy 2: Through a collaboration of professional associations and other stakeholders, 

*Note: While there is not strong evidence from clinical trials 

for determining therapy based on the domain of future risk, 

the guidelines Expert Panel considers that this is an 

important domain for clinicians to consider due to the strong 

association between history of exacerbations and the risk for 

future exacerbations.
24 National Asthma Education and Prevention Program Guidelines Implementation Panel Report

develop a range of innovative CME-based 

programs (webinars, teleconferences, CDROMs, grand rounds) to educate primary care 

clinicians and ED physicians and staff on how 

to assess asthma severity and articulate its 

significance to patients. 

Patients and Their Families

Recommendation: Educate patients who have 

asthma about the role of asthma severity in 

their overall asthma management. 

Strategy 1: Working with patient advocacy 

and education groups, professional associations and the NAEPP, convene a meeting 

to assess gaps in the availability of existing educational materials and resources 

for patients and families regarding asthma 

severity. Develop new educational materials 

and resources as needed with a focus on the 

domains of current impairment and future 

risk and their role in assessing asthma 

severity at diagnosis and then in monitoring level of asthma control once treatment 

is started. Disseminate resources through 

various channels available to educational 

groups and professional associations for use 

in patient education.

Strategy 2: Use a national campaign strategy 

and social marketing techniques to inform 

patients, their families and providers who 

care for them about the significance of 

assessing asthma severity at the time of a 

patient’s initial assessment to help determine 

the appropriate treatment plan.

System Integration

Rationale: All healthcare providers should be 

educated about the asthma guidelines and how to 

assess a patient’s asthma severity at initial diagnosis. In order to support the assessment of asthma 

severity, payors and purchasers of health benefits 

should understand the significance of asthma 

severity and the importance of the guidelines 

recommendation to assess it. Every healthcare 

professional who cares for people who have asthma 

should understand the concept of asthma severity 

and how to apply it in developing a treatment plan.

Education and Training Institutions

Recommendation: Educate clinicians-in-training 

(medical students, residents, nursing students, 

respiratory therapists, and pharmacists) on assessing asthma severity. 

Strategy 1: Working through the American Association of Medical Colleges, incorporate the 

concept of assessing asthma severity into the 

medical school curriculum.

Strategy 2: Through collaborative efforts of the 

professional associations, boards for various 

medical disciplines, and the NAEPP, develop 

tools to incorporate evaluation of asthma 

severity into training and MOC programs of 

primary care providers and clinicians (family 

practice, pediatricians, physician assistants, 

nurses, pharmacists, and respiratory therapists). 

Payors and Purchasers

Recommendation: Enlist payors and purchasers of 

services to promote the importance of assessing 

asthma severity by healthcare providers. 

Strategy 1: Encourage healthcare providers 

who participate in Medicaid, Medicare and 

large MCOs to conduct routine assessment of 

asthma severity on patients during their initial 

visit. Implement incentives and provide feedback reports.

Strategy 2: Explore the ability to use International Statistical Classification of Diseases and 

Related Health Problems and Current Procedural Terminology structures to better classify asthma severity. Coding should be better 

developed with respect to the coding of asthma 

severity.

Strategy 3: Engage professional associations in 

partnership with the NAEPP to work with EHR 

companies to include assessment of asthma 

severity in their system.

Strategy 4: Work with ED personnel, professional associations and hospital administrators 

to develop a process for evaluating asthma 

severity of all patients who have untreated or 

poorly controlled asthma and who are seen in 

the ED. The process that is developed should 

include methods for ED personnel to commu-
The GIP Implementation Plan: Recommendations and Strategies 25

nicate these severity level assessments to the 

patient’s primary care provider. 

Patient/Provider Support

Rationale: When being evaluated by healthcare 

providers, patients who have asthma should 

understand asthma severity and how it is assessed. 

They should expect that healthcare providers and 

clinicians who treat them understand the concept 

of asthma severity and how to apply it to a patient’s 

overall care.

Patient Advocacy Groups and Patients with 

Asthma

Recommendation: All patients who are 

diagnosed with asthma at the time of their initial 

assessment should have a determination made of 

their asthma severity. 

Strategy 1: Utilize a national asthma 

campaign to serve as an outreach arm to 

inform and educate patients and their 

families about all six priority messages, 

including basic information on why it is

 important for their provider to assess asthma 

severity when initiating therapy; and, on how 

to ask for and obtain an asthma severity assessment. 

Asthma Educators

Recommendation: Utilize asthma educators to 

teach their peers and other clinicians and educators, as well as patients and families about the 

importance of assessing asthma severity as well as 

the measures of impairment and risk that are used 

to determine level of severity. 

Strategy 1: Through the respective professional 

associations, patient advocacy and education 

groups in collaboration with the NAEPP’s 

National Asthma Control Initiative, develop 

tools to be used by asthma educators to teach 

patients and families, healthcare providers, 

managed care providers, pharmacists and others about asthma severity.

Strategy 2: Develop interactive, problem-based 

Train-the-Trainer programs for members of 

asthma educator organizations that teach key 

guidelines recommendations related to the six 

GIP messages, including asthma severity.

Strategy 3: Disseminate the educator training 

programs and the accompanying tools through 

a national asthma campaign as well as through 

other NAEPP partnering organizations.

Message: ASSESS AND MONITOR ASTHMA CONTROL.

At planned followup visits, asthma patients 

should review level of asthma control with their 

healthcare provider based on multiple measures 

of current impairment and future risk in order 

to guide clinician decisions to either maintain 

or adjust therapy. 

There is a new emphasis on the assessment and 

regular monitoring of asthma control to determine 

if the goals of therapy are being met and whether 

therapy needs to be adjusted. The EPR-3 emphasizes the distinction between classifying asthma 

severity and monitoring asthma control, namely, 

to assess asthma severity to initiate therapy and 

to assess asthma control to determine if therapy 

should be adjusted. Asthma control is the degree to which the manifestations of asthma are 

minimized by therapeutic interventions—that is, 

the degree to which the goals of therapy are met. 

Asthma control (just as asthma severity) includes 

the domains of current impairment and future risk. 

The concept of impairment includes frequency and 

intensity of symptoms, current or recent functional 

limitations experienced by the patient. The concept of risk includes the likelihood of either asthma 

exacerbations, progressive decline in lung function 

(or, for children, reduced lung growth), or risk of 

adverse effects from medication. The level of control achieved in response to treatment, including 

success of patient adherence to a realistic and 

goal-oriented treatment plan, dictates whether 

a treatment regimen can be maintained by the 

patient, or whether medication must be adjusted 

(stepped up or down). The emphasis of routine 

monitoring in the updated guidelines is clearly 

related to asthma control.

Communication

Rationale: In order to effectively communicate the 

role of assessing and monitoring asthma control 

in asthma management, clinicians and educators 

should understand patient perspectives on the 

concepts of impairment and risk and on the 

barriers patients face in implementing their 

treatment plans. Clinicians need tools and 
26 National Asthma Education and Prevention Program Guidelines Implementation Panel Report

resources to simplify presentation of the concept 

of control (impairment and risk) to patients and 

their families. Payors, PBMs, and Medicaid directors also need to understand the concept of control 

and its significance in asthma management since, 

through their direct access to high-risk populations, they have tremendous potential to impact 

asthma outcomes.

Patients and Their Families

Recommendation: Determine patients’ 

understanding of asthma control and the 

importance of monitoring it in long-term asthma 

management.

Strategy 1: Engage patient advocacy groups, 

patient education groups, practice-based 

research networks, and other stakeholders to 

review the literature on barriers to patients assessing and monitoring well-controlled asthma 

(drawing upon studies cited in the EPR-3 and 

other credible sources). Conduct focus groups, 

if needed, to further identify barriers to patients 

monitoring asthma control; include patients 

with asthma of all types, but especially those 

who have had exacerbations of their asthma in 

the past 2 years. Develop a white paper to summarize the barriers and propose methods for 

overcoming them, including ways to effectively 

convey the control message to patients and 

their families.

Strategy 2: Support the use of established social 

marketing and health communications techniques to develop culturally appropriate messages and media outreach activities by drawing 

upon academic and commercial entities with 

expertise in this discipline. 

Strategy 3: Utilize a national asthma campaign 

to implement a variety of social marketing and 

communication strategies that address all six 

messages, including asthma control.

Clinicians

Recommendation: Develop and deliver messages 

that enhance a clinician’s willingness to assess asthma control using standard measures of impairment 

and risk, with emphasis on high-impact strategies, 

e.g., MOC processes and board exams that could 

be applied across all six priority messages. 

Strategy 1: Conduct surveys or focus groups 

of clinicians and emergency medicine practitioners to evaluate the current clinical processes 

they use for determining a patient’s level of 

asthma control and explore ways to incorporate 

these familiar practices within the new framework of impairment and risk.

Strategy 2: Pilot test the use of board exams 

and the MOC processes within primary care 

and emergency medicine disciplines as a vehicle to support incorporation of guidelines into 

practice. This would involve dissemination of 

the guidelines, application of practice redesign 

elements to foster sustained implementation of 

the guidelines, and development of metrics to 

assess impact.

Strategy 3: Enlist the support of professional 

associations, patient advocacy and education 

groups, medical boards and other stakeholders 

to develop and disseminate innovative strategies for CME, nursing, and other healthcare 

disciplines’ education and MOC materials conveying the use of the EPR-3 recommendations 

for control in the management of asthma.

Managed Care Organizations, Payors and 

Pharmacy Benefits Managers

Recommendation: Identify gaps in existing tools, 

develop new tools as needed, and reach consensus 

on a standardized assessment tool for asthma control that incorporates the core concepts in EPR-3 of 

impairment and risk and that can be used in case 

management for monitoring of asthma control.

Strategy 1: Working with AHIP or BCBSA, 

convene a workshop of payors/PBMs aimed at 

developing an effective approach for communicating the EPR-3 recommendations on assessing and monitoring asthma control to payors 

and PBMs. Disseminate information on ways 

to implement the approach to constituents.

Strategy 2: Working through the NAEPP, coordinate a review of existing tools with MCOs 

and major purchasers of health care (e.g., large 

businesses, State governments, etc.); reach consensus among participants on a standardized 

tool, or template, for assessing and monitoring 

asthma control; develop new tools, if needed. 

The standardized tool would incorporate the 

core concepts of control, namely, impairment 
The GIP Implementation Plan: Recommendations and Strategies 27

and risk and could be used to monitor control 

during clinical and case management. Pilot test 

the tool, and also engage the NCQA as an ally 

to promote the piloted standardized assessment 

tool as an internal quality measure for use by 

MCOs. Adapt the tool to fit different populations and settings.

Strategy 3: Engage managed care entities to assess effective messaging techniques within their 

population reach in order to develop processes 

that better achieve effective self-assessment of 

asthma control by patients. Share this information with the broader MCO community.

Strategy 4: Through collaboration of the 

NAEPP and its partners, including possibly the 

IOM, develop a white paper on the effectiveness of MCOs to foster the implementation 

of guidelines through incentives, member 

outreach and provider collaboration. The 

paper should address how well MCOs foster 

enhanced disease management programs and 

should include an assessment of the effectiveness of these programs. Summarize and 

disseminate this information widely to Health 

Maintenance Organizations using a variety of 

formats.

Systems Integration

Rationale: Engage and collaborate with such 

entities as the NCQA and CMS to promote the 

asthma control message based on the domains of 

current impairment and future risk since these 

organizations exert far-reaching influence over 

employers’ health benefits purchasing decisions.

National Committee for Quality Assurance

Recommendation: Develop and implement 

a HEDIS measure that officially states the process 

of assessing control for managed care populations.

Strategy 1: The NAEPP in collaboration with its 

partners will support a NCQA working group 

to identify the foundational elements of asthma 

control measurements, based on risk and impairment, which can be parlayed into a uniform 

control measure for direct comparison from 

one plan to another. This performance measure 

should be designed to assess how well MCOs 

track asthma control in their case-managed 

population and in their membership overall. 

By monitoring this performance measure, an 

MCO will have demonstrated that it has 

integrated assessment of asthma control into 

its programs.

Strategy 2: Convene a meeting with MCOs to 

develop broad support for: 1) a HEDIS performance measure on asthma control assessment, 

2) the use of standardized tools in clinical settings, and 3) the use of case management.

Centers for Medicare and Medicaid Services

Recommendation: Promote programs that encourage assessment of asthma control in Medicaid 

recipients.

Strategy 1: Encourage strategic alliances with 

local and regional asthma coalitions, the 

Department of Medical Assistance Services in 

each state, and public health departments to 

disseminate information about disease management and other programs that incorporate 

asthma control messages for all recipients.

Strategy 2: Explore development of a formal 

plan that specifies assessment and monitoring of asthma control is provided in Medicaid 

disease management programs and provider 

continuing education programs. Furthermore, 

provide incentives to routinely assess asthma 

control in delivery of asthma care. 

Patient/Provider Support

Rationale: Although both providers and patients 

will readily mention asthma control as their 

primary goal for asthma management, they often 

neither employ a systematic way of assessing and 

regularly monitoring asthma control nor address 

the risks associated with lack of maintaining 

control. Physician organizations represent the 

clinicians, and oversee whether clinicians are 

performing or supervising appropriate assessment 

and monitoring of asthma patients. Patient advocacy groups represent those organizations 

that support the patient by helping to translate 

complex disease treatment steps into clear and 

simple self-management action messages, which 

include monitoring asthma control. Patients 

should monitor asthma control to better selfmanage their disease.

Patients and their Families

Recommendation: Encourage the expectation 

among people who have asthma and their families 
28 National Asthma Education and Prevention Program Guidelines Implementation Panel Report

that asthma control can be attained and will be 

assessed during their followup health visits.

Strategy 1: Conduct focus groups in diverse 

populations to collect information on patients’ 

understanding and beliefs related to asthma 

control and information on messaging related 

to monitoring asthma control as part of self 

management of their disease.

Strategy 2: Work with health communications 

experts, patient advocacy groups, and other 

stakeholders to develop culturally appropriate 

educational materials in a variety of formats 

and languages that address current knowledge, 

viewpoints, and potential misunderstandings 

of asthma control identified through the focus 

groups. Distribute these resources through the 

dissemination channels of patient and provider education groups and a national asthma 

campaign.

Professional Associations

Recommendation: Facilitate the ease with which 

physicians and other clinicians are more able to 

consistently and routinely conduct assessment of 

impairment and risk to determine their patients’ 

level of asthma control within varied practice 

settings. 

Strategy 1: Support sessions at professional 

association meetings that encourage participation in the development of decision support 

resources including Personal Digital Assistants, 

EHR clinical pathways, and patient educational 

materials designed to enhance the assessment 

and routine monitoring of asthma control. 

Strategy 2: Partner with professional 

associations to distribute useful materials and 

strategies through their existing 

electronic and mail member networks to help 

increase assessment and monitoring 

of asthma control.

Strategy 3: In collaboration with EHR vendors, 

develop and test an EHR/electronic clinical 

pathway template for asthma management that 

includes standard assessment tools for asthma 

control, standard data elements to support 

implementation, and evaluation. 

Strategy 4: Establish a partnership between 

the NAEPP and professional specialty boards 

to develop materials and strategies that can be 

incorporated into MOC programs.

Strategy 5: Convene stakeholders who have 

the expertise and resources to provide technical support for a series of quality improvement 

(QI) implementation studies. In collaboration 

with the NAEPP and its partners, develop these 

potentially high impact QI interventions to be 

tested by a partner organization or its practicebased research networks for effectiveness, 

transferability and sustainability. Facilitate 

assessment of QI interventions through grants 

and contracts offered by various government 

agencies or member programs in order to 

identify those with the highest possible impact. 

Patient Advocacy Groups

Recommendation: Develop messages that will 

encourage patients to self monitor their level of 

asthma control and that will foster expectations 

that their asthma control shall be routinely assessed by their healthcare provider for the longterm management of their asthma.

Strategy 1: Convene a meeting of leaders in 

public or media communication to work with 

patient advocacy groups and patient/provider 

education groups to:

•	 Develop messages for patients concerning

assessment and monitoring asthma control 

•	 Develop content that can be provided to

editors of State and local chapters of 

advocacy groups aimed at educating and 

empowering patients in preparation for 

interactions with their healthcare providers.

Strategy 2: Through community organizations, 

the local medical community and professional 

associations, develop presentation material to 

support existing or develop a new speakers’ 

bureau of clinicians, other healthcare professionals, patients and family members who are 

available for meetings and public events to 

convey and reinforce the message of monitoring asthma control.
The GIP Implementation Plan: Recommendations and Strategies 29

Message: SCHEDULE FOLLOWUP VISITS. 

Patients who have asthma should be scheduled 

for planned followup visits at periodic intervals in order to assess their asthma control and 

modify treatment if needed.

Asthma is highly variable. Some patients with 

asthma may have severe asthma attacks without 

many symptoms between attacks. Others, however, may have frequent symptoms without having 

a severe asthma attack. Asthma may also vary 

according to the time of year. Because response to 

asthma therapy may vary, periodic monitoring of 

asthma control through clinical visits is essential 

to “step up” therapy (increase the dose, number of 

medications and frequency) as necessary; or, “step 

down” (decrease) when possible to the minimum 

medication necessary to maintain control. The interval between followup visits may also vary based 

on the level or duration of asthma control as well 

as the level of treatment required.

The frequency of monitoring is a matter of clinical judgment and will vary depending on several 

factors, including the level of asthma control. In 

general, patient visits should be scheduled at 2-to6 week intervals while initiating therapy or stepping up therapy to achieve control; at 1-to-6 month 

intervals after asthma control is achieved in order 

to monitor if asthma control is maintained; and, 

at 3-month intervals if a step-down in therapy is 

anticipated.

Communication

Rationale: Patients and their families, clinicians, 

healthcare administrators and policymakers may 

lack knowledge and appreciation about the importance and benefit of periodic clinical followup 

of people who have asthma. Contributing factors 

include the complexity of the message related to 

routine “check ups” for asthma, even when the 

patient is feeling fine, versus the tendency to visit 

the doctor only during an asthma attack; and to a 

lack of belief in the benefits of preventive care. A 

message that focuses on mutually agreed-upon 

goals for therapy, objective measures of control, 

and the benefits of well-controlled asthma would 

be a motivational cue to patients for keeping their 

appointments. 

Patients and Families

Recommendation: Implement a national asthma 

campaign to educate, in particular, high-risk population segments about the importance of regularly 

scheduled outpatient followup in accordance with 

the EPR-3 for people who have asthma.

Strategy 1: Conduct social marketing and 

health communications research to develop 

accurate and consistent, consumer-friendly 

messages and identify appropriate media channels to reach people who have asthma from different cultural backgrounds and literacy levels.

Strategy 2: Conduct a pilot project for segments 

of the U.S. general public to evaluate the effectiveness of these messages in changing asthma 

knowledge, attitudes, and behaviors about periodic visits and other EPR-3 priority messages 

related to long-term management. The pilot 

project and its evaluation should examine the 

projected costs and benefits to expanding this 

pilot project to the entire population. Present 

the results of the pilot project as a business case 

for periodic visits. 

Clinicians

Recommendation: Develop and deliver messages to 

primary care providers and ED clinicians regarding the importance of routine clinical followup for 

patients who have asthma.

Strategy 1: Work with professional associations, specialty organizations, certification 

boards, and educational training programs to 

include the message of periodic visits in their 

CME and MDC programs.

Strategy 2: Work with industry in developing 

and delivering effective educational and motivational strategies to promote periodic visits.

Purchasers and Payors

Recommendation: Increase awareness of the potential benefits of consistent outpatient followup 

among major purchasers of health benefits, payors, 

and health actuaries as a move toward broad-scale 

insurance coverage of periodic visits in routine 

asthma care. 

Strategy 1: Conduct a series of interviews with 

private and public payors to assess and summarize potential benefits and barriers to the 

implementation of comprehensive outpatient 

insurance coverage for asthma. 
30 National Asthma Education and Prevention Program Guidelines Implementation Panel Report

Strategy 2: Work with patient advocacy groups 

to gather and disseminate existing information 

on the costs and benefits of periodic outpatient 

asthma care as compared to sporadic asthma 

care. This information will be disseminated 

to purchasers and payors in presenting a case 

for covered periodic asthma care. Include 

recommendations promoting appropriate 

reimbursement for services provided at 

routinely scheduled outpatient visits.

Systems Integration

Rationale: There are multiple barriers within the 

healthcare system and community that contribute 

to the lack of periodic clinical followup of patients 

who have asthma. Several major barriers include 

lack of monitoring systems to track patients who 

have asthma, insufficient incentives or prompts 

for patients to encourage adherence to treatment 

plans, and lack of consistent reimbursement for 

followup visits. 

Clinical Practice Gatekeepers (Administrators/

Policy Makers), Private and Public

Recommendation: Implement patient monitoring 

and referral policies that will promote the increase 

of appropriate outpatient followup for persons who 

have asthma, with special attention to implementing close followup after an urgent care encounter 

for those whose asthma is not well controlled.

Strategy 1: Convene a group of medical directors, clinicians, and clinic administrative staff 

from varied healthcare settings to identify barriers to followup care and use this information 

to develop innovative strategies to overcome 

the barriers. An example of such a strategy is 

an automatic generation of lists of patients who 

are at higher risk and greater need for followup 

based on their lack of asthma control.

Strategy 2: Conduct a QI study in a few of the 

NAEPP’s partner organizations to evaluate 

the effectiveness of several monitoring and 

referral strategies and their potential for broader dissemination and implementation. Identify 

the high impact strategies to replicate within 

an expanded implementation initiative.

Clinicians and Healthcare Providers

Recommendation: Develop, implement, and 

evaluate QI strategies that promote outpatient 

followup for asthma care.

Strategy 1: In collaboration with public and 

private healthcare providers and educators 

and their respective organizations, convene 

focus groups including clinicians from various 

types of clinical settings and disciplines (e.g., 

primary care physicians, nurse practitioners, 

specialists, physician’s assistants, respiratory 

therapists, pharmacists) to generate QI 

strategies that are simple and feasible.

Strategy 2: Develop and implement 

strategies targeted to patients who have asthma 

and are discharged from the ED or hospital. 

These strategies could include staff education 

or a reminder system for the hospital and 

ED staff.

Strategy 3: Develop and implement strategies 

that use pharmacy databases and EHRs to establish reminder systems for clinicians working 

in different healthcare settings.

Strategy 4: Explore use of “alternative” 

followup appointments, e.g., “e-mail appointments” where e-mails are exchanged to see if 

an office visit or change in prescription is warranted.

Purchasers and Payors 

Recommendation: Examine insurance coverage

gaps and other barriers linked to the possible 

underutilization of routine outpatient followup 

visits and develop solutions to overcoming these 

barriers.

Strategy 1: Work through a national asthma 

policy forum, in coordination with the NAEPP, 

to convene a consortium of private and public 

healthcare purchasers and payors, as well as 

selected members from the GIP to examine 

systems barriers to appropriate utilization of 

outpatient followup visits. The consortium 

would develop and evaluate strategies designed 

to overcome the barriers.

Strategy 2: Conduct a study that compares 

current costs associated with utilization of 

outpatient clinics by asthma patients, who are 

seen across a variety of healthcare settings, 

with the current costs associated with inpatient 

hospital admissions for asthma (including cost 

of medications). Use the results to document 

whether costs of outpatient care are a barrier to 
The GIP Implementation Plan: Recommendations and Strategies 31

reimbursement for periodic clinical care; and/

or whether costs explain the reason for a 

discrepancy in time intervals between actual 

followup visits and the intervals recommended 

in the EPR-3. 

Strategy 3: Encourage consortium members to 

develop performance measures/benchmarks 

for appropriate followup care that are based on 

EPR-3 and that would be feasible to track 

for QI and performance measure purposes. 

Strategy 4: Encourage consortium members 

to use the asthma outpatient care quality 

benchmarks to conduct a series of pilot studies. These studies would be used to evaluate 

the feasibility and benefit of strategies, such 

as pay-for-performance, to close the gaps that 

contribute to underutilization of outpatient 

follow up visits.

Patient/Provider Support

Patients and providers should follow the 

recommended actions for periodic visits, such as 

patient attendance at regularly scheduled clinical 

appointments and provider adjustment of medication (stepping up or down as needed), to facilitate 

meeting the goals of therapy and better control 

of asthma. If certain tools and resources, e.g., 

access to appropriate medications as determined 

by the physician, are made available to patients and 

providers, patient’s motivation and willingness to 

follow through with recommended actions may be 

improved.

Patients with Asthma

Recommendation: Implement educational and 

motivational strategies that can be broadly disseminated among all patients who have asthma.

Strategy 1: Encourage healthcare providers to 

send patients hard-copy and electronic reminders, or telephone reminders of followup schedules, including a brief and easy-to-understand 

list of what to expect from their asthma followup appointment.

Strategy 2: Develop policies among healthcare 

insurance companies to provide incentives for 

outpatient followup clinical evaluation. 

Strategy 3: Educate all persons who have 

asthma and their families about the importance 

of outpatient followup care as part of a national 

asthma campaign and the broader NAEPP 

partnership activities. 

Clinicians

Recommendation: Develop and provide 

clinicians with “user friendly” and practical tools 

to support their followup assessment of asthma 

control, adjustment (or maintenance) of medications, and review of patient self-management skills 

for patients who have asthma.

Strategy 1: Convene a working group of GIP 

members and community-based clinicians to 

identify barriers faced by clinicians that may 

affect their capacity and motivation in implementing periodic asthma check-up visits. 

Strategy 2: In light of the identified barriers, 

determine how to clearly and simply present information from the EPR-3 on followup 

monitoring. Summarize this information and 

disseminate widely to a varied group 

of clinical audiences so they may adapt the 

information for use in their particular 

settings.

Strategy 3: Work with stakeholders, including 

the private sector and professional associations, to disseminate a targeted and simplified 

educational and motivational program to all 

clinicians that addresses the described barriers. 

This could include innovative CME activities 

informed by focus groups, as well as educational and motivational programs that integrate 

messages about periodic visits with other key 

messages from EPR-3 as well. This strategy 

could be carried out through a national asthma 

campaign in collaboration with the NAEPP 

and other interested partners,

Schools, School Nurses, and School-based 

Health Centers

Recommendation: Facilitate communication 

between primary care provider’s offices and 

schools about students’ AAP, the role and value 

of them, including the need for periodic followup 

visits as an integral element of the treatment.

Strategy 1: Working with the NAEPP School 

Education Subcommittee and the Center of 

Disease Control (CDC) working group on 
32 National Asthma Education and Prevention Program Guidelines Implementation Panel Report

AAPs, conduct focus groups consisting of 

school personnel and parents to identify 

barriers and explore ways that schools might 

facilitate students making and keeping 

clinic appointments for periodic asthma 

followup care.

Strategy 2: Working with the above groups, 

brainstorm strategies and tools that could be 

used to address these barriers. Strategies could 

include asthma clinic times after school or a 

requirement that proof of an asthma clinical 

evaluation be provided at the beginning of the 

school year.

Strategy 3: Pilot test the strategies and tools in 

selected schools and disseminate the results.

Message: CONTROL ENVIRONMENTAL EXPOSURES 

Clinicians should review each patient’s exposure to allergens and irritants and provide a 

multipronged strategy to reduce exposure to 

those allergens and irritants to which a patient is 

sensitive and exposed, i.e., that make a patient’s 

asthma worse. 

Evidence demonstrates that, for an allergen- and 

irritant-sensitive person who has asthma, substantially decreasing exposure to inhalant allergens 

may significantly reduce inflammation, symptoms, 

and the need for medication. Furthermore, certain 

respiratory irritants such as tobacco smoke and air 

pollution are associated with increased symptoms 

and increased use of healthcare services. Therefore, a patient’s AAP should identify individual 

allergens and irritants that worsen the patient’s 

asthma. This information may assist in avoiding 

unnecessary exposures to allergens/ irritants, or at 

least be an alert to exposures that might indicate a 

need for increased therapy. Also, clinicians should 

consider a patient’s success with efforts to reduce 

exposure to allergens and irritants as part of his/

her decision to step up or down treatment for 

the long-term management of asthma. Exposure 

control of allergens and irritants at home, school 

or work is an important measure for achieving 

well-controlled asthma and is likely to improve 

the allergen- and irritant-sensitive patient’s quality 

of life. Community resources, including in-home 

support for allergen and irritant reduction, are 

helpul in controlling environmental factors that 

can make asthma worse.

Communication

Rationale: Conducting an initial environmental 

assessment for patients who have asthma at any 

level of severity should provide information that 

the clinician can use to educate patients on actions 

to take toward reducing exposure to those allergens and irritants that worsen a patient’s asthma. 

Using multiple approaches to reduce exposure 

to known allergens/irritants is imperative for 

effective exposure control since individual steps 

are generally ineffective.

Conducting a more detailed environmental assessment in the patient’s home (or other settings where 

a patient spends considerable time, such as school 

or work) may also be useful for certain patients 

(e.g., those whose asthma is not well-controlled or 

whose asthma is work related). 

For patients who have persistent asthma and are 

exposed to indoor allergens year round, followup 

steps to an initial environmental assessment may 

include allergy testing to determine sensitivity to 

allergens, with results considered in the context of 

the patient’s overall medical history. Conducting 

skin or in vitro testing to confirm sensitivity helps 

to narrow the focus of a patient’s allergen/irritant 

exposure control strategy to those factors that will 

have the greatest effect. 

Clinicians

Recommendation: Provide clinicians with 

user-friendly, systematic and step-wise techniques 

and tools for evaluating a patient’s environmental 

exposures and their possible role in the patient’s 

asthma. These techniques/tools should include 

guidance to aid the clinician in determining when 

an initial environmental assessment by history 

alone is sufficient, and when a more complete inhome, school or work assessment is needed. The 

techniques/tools should also address when allergy 

testing and referral to a specialist is recommended 

based on EPR-3. 

Strategy 1: As part of planning a national asthma campaign that addresses all six GIP messages, work in collaboration with the NAEPP 

and its partners to include a message encouraging clinicians to identify environmental factors 

that worsen a patient’s asthma and to consider 

the patient’s success with efforts to control factors capable of making asthma worse as part 

of the clinician’s decision to step up or down 
The GIP Implementation Plan: Recommendations and Strategies 33

treatment for the long-term management 

of asthma. 

Strategy 2: Convene a workshop of experts in 

environmental control, asthma specialists, primary care providers, asthma educators, patient 

advocacy groups, employers and worker advocates to review existing tools and, as needed, 

develop new tools and protocols. Proposed 

tools and protocols should address a variety 

of clinical settings and patient cultural/ethnic 

situations. The tools should be built upon the 

core elements of an environmental assessment 

identified in EPR-3. The tools should also offer 

selection criteria for complementary types of 

assessments (interview, in-home/at school or 

work), and for allergy skin or in vitro testing. 

Disseminate the resulting products to healthcare practitioners who treat asthma. 

Strategy 3: Convene a workgroup of primary 

care providers, allergists, representatives of 

health plans, and State Medicaid Medical 

Directors to explore barriers to allergy testing 

in primary care settings to reach consensus 

on, and implement policies for, supporting the 

use of allergy testing in accordance with EPR-3 

recommendations; and, to facilitate referrals to 

specialists, as appropriate, for consultation or 

comanagement of patients.

Schools, School Nurses, Childcare Centers, and 

Schoolbased Health Centers:

Recommendation: Inform school/childcare personnel about the potential impact of their site’s 

environment on students’ management of their 

asthma. Provide education on allergens and irritants frequently found in schools/childcare centers 

and on what the role of school staff is in helping 

students and staff who have asthma with their 

exposure control strategies. Focus specifically on 

those environmental factors identified in AAPs 

on file for students who have asthma. Provide 

affordable, practical solutions for schools/childcare 

centers to use for allergen/irritant reduction.

Strategy 1: The NAEPP School Education 

Subcommittee in collaboration with interested 

professional associations, patient education 

groups, boards of education, and government 

agencies, should reference the EPR-3 to collate a 

summary of the evidence regarding the impact 

of allergen and irritant exposure on asthma 

control that is tailored to a school audience. 

Identify and disseminate tools and strategies 

that have been proven to reduce allergens and 

irritants in school and childcare environments 

and improve students’ asthma outcomes. 

Strategy 2: Build upon existing (and establish 

new, if needed) methods and tools for contacting schools and childcare centers and orienting 

appropriate personnel on the importance of 

controlling environmental factors in the management of asthma.

Strategy 3: Engage asthma coalitions, professional associations, government agencies, 

asthma educators, school administrators, school 

educators and nurses at the State or local level 

to develop and implement a coordinated plan 

of action to reduce exposure based on proven 

approaches identified in Strategy 1 above. 

Strategy 4: Establish a system of communication or leverage an existing network among 

designated school or childcare staff, asthma 

educators, the student and student’s family, 

school staff who have asthma, and healthcare 

providers to help exchange information about 

and coordinate control of the allergens and 

irritants in the school or childcare setting that 

worsen asthma.

Workplace

Recommendation: Inform healthcare providers, 

patients, occupational specialists, health benefits 

managers, payors, employee unions/ associations, 

and healthcare coordinators at the workplace about 

allergens and irritants found in the workplace that 

may cause or exacerbate asthma. Provide education on preferred approaches for controlling exposure to these allergens and irritants. Encourage 

providers to document work exposures to allergens 

and irritants in the patient’s medical record and 

make work-related asthma a reportable condition. 

Encourage population monitoring and registries.

Strategy 1: Summarize evidence cited in EPR-3 

and other credible scientific literature that 

describes the impact allergens and irritants 

found in the workplace can have on asthma, 

and preferred approaches to controlling these 
34 National Asthma Education and Prevention Program Guidelines Implementation Panel Report

exposures. Disseminate the summary to 

stakeholders in various presentation formats 

and through their existing communication 

channels.

Strategy 2: Coordinate with the workshop strategy described above under Communications, 

Clinicians, Strategy 2 to review existing tools 

that assess the association between asthma 

symptoms and exposures in the work 

environment. Select sample(s), or develop 

a new tool, if needed, for dissemination to 

healthcare providers, patients, and worksites 

that is practical and easy to use.

Patients and Families

Recommendation: Develop and deliver messages 

to patients that help them understand the importance and ways of reducing exposure to allergens 

and irritants that can make asthma worse. 

Address with employers the barriers to and 

resources for changing workplace environments, 

including strengthening linkages to community 

resources. 

Strategy 1: Engage partners to use social marketing and health communications approaches, 

possibly including focus groups with patients, 

for insight on messages, strategies and resources to effectively overcome barriers to controlling or eliminating allergen/irritant exposures 

in their immediate environments—home, 

school, childcare centers and work. 

Strategy 2: Obtain feedback from focus groups 

on content and formatting of tips sheets for 

presenting environmental changes that would 

overcome barriers and that are readily achievable within the constraints of existing resources 

and current practices in the home, school, 

childcare centers and workplace. 

Systems Integration

Rationale: Coordinate actions to control exposure 

to allergens and irritants among clinicians, public 

health providers, asthma educators, school and 

childcare staff, members of Boards of Education, 

employers, workplace staff, and health plan administrators. Encourage systems that document 

instructions given for identifying allergens/irritants to which a patient is sensitive in the patient’s 

chart; and, that also document the environmental 

control measures a patient agrees to and is able 

to take. Documentation increases patient and 

clinician accountability for the implementation of 

environmental control measures and provides data 

for monitoring such activities.

Commercial Health Plans and 

Healthcare Payors

Recommendation: Seek coordination and agreement among health plans and payors on actions 

taken with respect to environmental assessment, 

intervention, and monitoring, and on documenting these actions in the patient’s medical chart. 

Documentation includes any referrals made to 

specialists for further testing.

Strategy 1: Convene managed care companies to work with NCQA to develop a HEDIS 

measure of environmental assessment and 

monitoring (including monitoring success 

with adherence to an allergen/irritant exposure 

control strategy); prepare a dissemination and 

implementation plan for the HEDIS measure 

and tools; garner broad support for use of the 

measure and accompanying implementation 

tools. 

Strategy 2: Working through a national asthma 

policy forum, collaborate with the NAEPP and 

its partners to convene a workshop of professional associations, patient education groups, 

health plans/payors and other stakeholders to 

develop policies and protocols for referral and 

reimbursement of allergen/irritant-exposure 

control education, in-home education specifically tailored to the individual patient, in-home 

and at-work assessments, and in-home support.

Strategy 3: Convene a meeting of managed care 

companies to discuss and formulate strategies 

on how to incorporate and track environmental 

assessment activities in their pay-for-performance systems. 

Electronic Health Record Companies

Recommendation: Embed assessment and monitoring of environmental factors at home, school 

and work and a patient-tailored exposure control 

strategy into the EHR. Build verification into the 

system that clinicians considered the patient’s 

efforts to control factors capable of making asthma 

worse before stepping medication up/down in 

asthma patients who are not well controlled. The 

availability of resources for conducting environ-
The GIP Implementation Plan: Recommendations and Strategies 35

mental assessments and educating patients on allergen/

irritant exposure control within the EHRs will encourage 

clinician use and accountability. 

Strategy 1: Encourage the NAEPP and its partners, 

working in collaboration with EHR companies, 

to establish agreed-upon samples of environmental- and occupational-assessment questions and 

exposure control strategies for inclusion in EHRs.

Strategy 2: Encourage EHR companies to create 

a system in the EHR that prompts the use of 

environmental/occupational assessment questions 

and exposure control strategies for clinicians to 

use with their asthma patients, e.g., prompts and 

decision supports.

Patient/Provider Support

Rationale: Provide education and resources to patients, 

families and caregivers to help reduce allergen exposure, 

emphasizing that this is an important component of 

asthma selfmanagement that should improve the patient’s 

asthma control and quality of life. Patient concerns and 

obstacles faced in changing their environments to reduce 

allergen/irritant exposure must be considered in selecting and designing effective educational materials, programs and strategies. In order to enhance the implementation of exposure control measures, intervention tools 

and education should be provided to healthcare providers and asthma educators to assess exposure and sensitivity to allergens and irritants and to help them develop 

tailored allergen/irritant exposure control strategies. 

Patients, Their Families and Caregivers

Recommendation: Provide resources (especially for patients with persistent asthma) that are deemed necessary 

for allergen and irritant reduction based on a patient’s 

sensitivities and exposures. This applies to patients who 

are exposed to and sensitive to allergens, irritants and 

environmental tobacco smoke (ETS). Resources may 

include, but not be limited to: in-home supplies and 

services; programs on smoking cessation and ETS; 

information and referral to health, housing and social 

services; and, patient education programs and materials. 

These resources should be available in culturally sensitive 

venues and include low literacy and multi-lingual patient 

materials, programs and other strategies.

Strategy 1: Utilize results from the CDC Community 

Guide Task Force on Community Preventive Services 

(developed with representation from researchers, 

public health officials, health educators, certified 

asthma educators, and people diagnosed with 

asthma) that reviews current evidence for 

in-home interventions and the tools used for 

implementation of such programs.

Strategy 2: Identify existing repositories for, or 

gather information on, environmental control 

education resources such as educational programs, print materials, videos, and computerbased applications. Use existing or develop 

new criteria to identify samples of “model” 

materials and programs that are posted to a 

virtual repository for asthma stakeholders. Disseminate information to stakeholders about the 

established Web site and the model materials 

and programs and other resources found there 

and how to access them.

Strategy 3: Encourage professional societies, 

government agencies and other NAEPP partners to disseminate their print materials to constituents on request and to post them on their 

respective Web sites for easy access by patients, 

providers and the public. Also, post video and 

computer-based programs on each organization’s respective Web site, and consider links to 

resources on each other’s sites. 

Strategy 4: Encourage asthma specialists, nurse 

coordinators, asthma educators, and community healthcare professionals and workers 

to disseminate materials to patients and the 

public in local communities and make referrals 

for persons who have asthma to appropriate 

programs and services.

Strategy 5: Leverage existing asthma stakeholder networks and structures to create new channels of support for an overall national asthma 

campaign to promote the GIP messages. These 

new channels would utilize media (TV, magazines), patient advocacy groups, and State and 

local agencies to help disseminate messages 

including ETS and allergens and irritants that 

aggravate asthma.

Providers

Recommendation: Provide the appropriate 

support education and tools for assisting healthcare providers in the assessment of allergens and 

irritants. Encourage clinicians to include such 

assessment as a key clinical activity to asthma care. 
36 National Asthma Education and Prevention Program Guidelines Implementation Panel Report

Strategy 1: Prompt primary care providers via 

EHRs or office system prompts to obtain exposure and sensitivity information for indoor and 

outdoor environmental allergens and irritants 

to record in the patient’s chart. 

Strategy 2: Promote inclusion of exposure and 

sensitivity assessment of indoor and outdoor 

environmental allergens and irritants and the 

reduction methods advised for persons who 

have asthma as part of the curriculum of undergraduate, graduate and continuing education for 

physicians, nurses, respiratory therapists, asthma 

educators, and other related health care professionals. Different requirements should be developed for different categories of educators, such 

as professional-level educators, nurses, masterstrained educators, and community level workers.

Strategy 3: Develop training resources and 

protocols to promote allergy testing in primary 

care sites, including preparation to deal with 

possible anaphalaxis.
Partners Putting Guidelines 

Into Action 

Guidelines Implementation Panel Report for: Expert Panel Report 3—Guidelines for the 

Diagnosis and Management of Asthma

Appendices 37
38 National Asthma Education and Prevention Program Guidelines Implementation Panel Report

aPPendIX a

Ranking the Level of Evidence for Asthma Guidelines 

Recommendations

The system used to describe the level of evidence is 

as follows (Jadad et al. 2000): 

n Evidence Category A: Randomized controlled 

trials (RCTs), rich body of data. Evidence is 

from end points of well-designed RCTs that 

provide a consistent pattern of findings in 

the population for which the recommendation 

is made. Category A requires substantial 

numbers of studies involving substantial 

numbers of participants. 

n Evidence Category B: RCTs, limited body of 

data. Evidence is from end points of intervention studies that include only a limited number 

of patients, post hoc or subgroup analysis of 

RCTs, or meta-analysis of RCTs. In general, 

Category B pertains when few randomized 

trials exist, they are small in size, they were 

undertaken in a population that differs from 

the target population of the recommendation, 

or the results are somewhat inconsistent. 

n Evidence Category C: Nonrandomized trials 

and observational studies. Evidence is from 

outcomes of uncontrolled or nonrandomized 

trials or from observational studies. 

n Evidence Category D: Panel consensus 

judgment. This category is used only in cases 

where the provision of some guidance was 

deemed valuable, but the clinical literature 

addressing the subject was insufficient to justify 

placement in one of the other categories. The 

Panel consensus is based on clinical experience 

or knowledge that does not meet the criteria for 

categories A through C.

Jadad AR, Moher M, Browman GP, Booker L, Sigouin 

C, Fuentes M, Stevens R. Systematic reviews and metaanaltses on treatment of asthma: critical evaluation. BMJ 

2000;320(7234):537-40
App

Establishing a Framework of Patient-centered Care for 

Developing the GIP Implementation Plan

Appendix B 39

In order to ensure consistency in recommendations, GIP members agreed that strategies should 

be patient focused and utilize a patient-centered 

chronic care model (CCM) concept. Core recommendations that build on quality initiatives 

must begin by considering the patient’s wants and 

needs first. Many CCMs centralize the focus on 

system changes or healthcare provider functions 

or pathways. GIP members agreed that unless the 

patient is provided appropriate asthma education 

and is actively involved in his/her own care, the 

likelihood of asthma management being successful 

is less likely. GIP members also acknowledge that 

there are issues that exceed the resources of the 

sole practitioner/clinician. Therefore, using a team 

approach based on the patient CCM could improve 

the likelihood of successful treatment.

In order for a patient to actively and successfully 

participate in his/her own asthma management 

plan, clinicians should work inclusively by using 

resources that are outside the clinic office and are 

often underutilized. Referrals to outside agencies (both community and professional) require a 

clinician to be knowledgeable about what resources 

are available, affordable and accessible within the 

patient’s community. Referrals to specific services 

may be provided by certified asthma educators, 

and can include case management through insurance, in-home asthma education and environmental evaluations through licensed home care agencies, school health office followup, social services 

and others. In addition, “healthcare services 

that are utilized and fit a patient centered model 

should also be safe, effective, timely, efficient, 

and equitable.”1

Patient-centered chronic care systems encourage patient, family and caregiver education that 

promotes effective self-management skills. “Selfmanagement differs from telling patients what to 

do in that patients have a central role in determining their care, one that fosters a sense of responsibility for their own health.” 1

 Effective support for 

patient self-management includes increasing patient participation in planning and individualized 

treatment plans with collaborative personal goalsetting. Treatment decisions need to be founded 

on evidence-based, nationally accepted guidelines 

and be mindful of the patient’s personal values, 

beliefs and lifestyle. Health care organizations 

should work to integrate national guidelines into 

the day-to-day practice of the primary care providers in an accessible and easy-to-use manner and 

utilize quality measurement standards to reward 

positive health outcomes of patients. Furthermore, 

“the delivery of patient care requires not only 

determining what care is needed, but clarifying 

roles and tasks to ensure the patient gets the care; 

making sure that all the clinicians who take care of 

a patient have centralized, up-to-date information 

about the patient’s status; and making followup a 

part of standard procedure.”1

Well developed and implemented patient-centered 

care models foster productive interactions between 

informed patients who are actively participating 

in their asthma care and providers with the proper 

resources and expertise to help guide them. 

Improving Chronic Care. 

The central issues to improving chronic care 

through patient-oriented systems changes include:

•	 Patient Safety—Health system

•	 Cultural Competency—Delivery system design

•	 Care Coordination—Health system; Clinical

information systems

•	 Community Policies—Community resources

and policies

•	 Case Management—Delivery system design

In the above list each of these issues is paired with 

a functional aspect of the healthcare system which, 

if targeted for quality improvement, will likely 

result in positive change.
40 National Asthma Education and Prevention Program Guidelines Implementation Panel Report

Below is a list of the five issues followed by an 

overall objective and specific strategies to achieve 

the objective.

(Adapted from Improving Chronic Illness Care2

, 

http://www.improvingchroniccare.org) 

Patient safety—Health System 

Create a culture, organization, and mechanisms that 

promote safe, high-quality care.

•	 Visibly support improvement at all levels of the

organization, beginning with the senior leader. 

•	 Promote effective improvement strategies

aimed at comprehensive system change. 

•	 Encourage open and systematic handling of

errors and quality problems to improve care. 

•	 Provide incentives based on quality of care.

•	 Develop agreements that facilitate care

coordination within and across organizations. 

Cultural competency—Delivery System Design

Self-Management Support

Empower and prepare patients to manage their 

health and healthcare.

•	 Emphasize the patient’s central role in

managing their health. 

•	 Use effective self-management support

strategies that include assessment, goalsetting, 

action planning, problemsolving and 

followup. 

•	 Organize internal and community resources

to provide ongoing self-management support 

to patients. 

Care coordination—Health System and Clinical 

Information Systems

Decision Support

Promote clinical care that is consistent with scientific 

evidence and patient preferences.

•	 Embed evidence-based guidelines into daily

clinical practice. 

•	 Share evidence-based guidelines and

information with patients to encourage their 

participation. 

•	 Use proven provider education methods.

•	 Integrate specialist expertise and primary care.

Organize patient and population data to facilitate 

efficient and effective care.

•	 Provide timely reminders for providers and

patients. 

•	 Identify relevant subpopulations for proactive

care. 

•	 Facilitate individual patient care planning.

•	 Share information with patients and providers to

coordinate care. 

•	 Monitor performance of practice team and care

system. 

Community policies—Community Resources 

and Policies

Mobilize community resources to meet needs 

of patients.

•	 Encourage patients to participate in effective

community programs. 

•	 Form partnerships with community organizations to support and develop interventions that 

fill gaps in needed services. 

•	 Advocate for policies to improve patient care and

asthma-friendly community environments (e.g., 

no smoking policies).

Case management - Delivery System Design

Assure the delivery of effective, efficient clinical care 

and self-management support.

•	 Define roles and distribute tasks among team

members. 

•	 Use planned interactions to support evidencebased care. 

•	 Provide clinical case management services for

patients whose asthma is difficult to control, 

who have significant co-morbidities affecting 

their asthma, or have difficulties following their 

asthma action plan.

•	 Ensure regular followup by the care team.

•	 Give care that patients understand and that fits

with their cultural background. 

Summary of Patient Care Model/Improving 

Chronic Illness

While the GIP chose to base its recommendations 

for implementation on a patient-centered model, 

there is no one individual model that fosters change 

in the health care system. All models contain 

similar concepts and goals and employ strategies 

that seek changes from all entities involved in the 

complicated American health system. This guide 

seeks to encourage health systems, providers, supporting businesses and organizations, patients, their 

families and caregivers to seek high-quality care 

and to become involved in making changes in the 

current care system. Further information regarding 

the many concepts and models of the CCM can be 

found by accessing the listed resources. 
Appendix B 41

References: 

Excerpts from “Crossing the Quality Chasm: 

A New Health System for the 21st Century, 

Committee on Quality of Health Care in 

America, Institute of Medicine, The National 

Academies 2001.

“Improving Chronic Illness Care” —http://www. 

improvingchroniccare.org/

Bibliography:

•	 Institute for Healthcare Improvement

(www.IHI.org) 

•	 Wagner EH. Chronic disease management: 

what will it take to improve care for chronic 

illness? Eff Clin Pract. 1998; 1:2-4 

•	 Wagner EH, Austin BT, Davis C, Hindmarsh 		

M, Schaefer J, Bonomi A. Improving chronic 

illness care: translating evidence into action. 

Health Aff (Millwood). 2001;20:64-78.
42 National Asthma Education and Prevention Program Guidelines Implementation Panel Report

App

Health Disparities

A crosscutting theme of this GIP report that 

transcends all six messages is to reduce health 

disparities from asthma. The burden of asthma is 

not uniform across all populations. Low-income 

people and racial and ethnic minorities are disproportionately affected. Asthma prevalence is 25 

percent higher among American Indian or Alaska 

Native children, 60 percent higher among black 

children and 140 percent higher among Puerto 

Rican children relative to white children. Black 

children have a 260 percent higher Emergency 

Department (ED) visit rate and a 250 percent 

higher hospitalization rate from asthma compared 

to white children. Despite the higher burden of 

disease among these populations, access to medical 

care for asthma and the quality of care provided 

is often lower among the minority and socio-economically disadvantaged populations. Exposure 

to asthma triggers is also more frequent. These 

disparities in asthma burden and care suggest that 

special efforts are needed to implement the EPR-3 

guidelines in these populations.

All stakeholders involved in controlling asthma 

have a role to play in reducing asthma-related 

health disparities. The GIP suggests that the 

stakeholders consider the following strategies.

Improving the quality of medical care. 

Health Resources and Services Administration 

(HRSA) Federally Qualified Health Centers 

(FQHCs), public hospitals, insurers with lowincome members, Medicaid agencies)

•	 Support quality improvement efforts among

 safety-net providers. These efforts may 

 include registry development, electronic 

 health records, quality improvement 

 collaboratives, audit and feedback and 

 organizational redesign. 

•	 Assure the cultural appropriateness of care,

 including the cultural competence of 

 providers through the provision of training 

 and toolkits, access to interpreters, 

 adherence to Culturally and Linguistically 

 Appropriate standards, and provision 

 of translated and culturally relevant patient 

 education resources. 

•	 Help providers and patients develop more

 effective communication by training 

 providers in cross-cultural, patient-centered 

 methods and by teaching patients to bring 

 their concerns and questions to their provider 

 visits.

Improving self-management support. 

•	 Offer home visits by community health

 workers to patients with uncontrolled asthma 

 (e.g., disseminate Integrated Condition 

 Assessment System and Healthy 

 Homes programs), (nongovernmental 

 organizations (NGOs), local health 

 departments, FQHCs).

•	 Provide community-based asthma education

 classes (NGOs, local health departments, 

 FQHCs).

•	 Reimburse for self-management support

 (Medicaid, insurers).

Improving care coordination and case 

management. 

•	 Coordinate primary care with specialty care,

 schools and community resources through 

 patient care coordinators or health system 

 navigators (FQHCs, NGOs).

•	 Provide case management for patients with

 high risk for exacerbations (NGOs, local 

 health departments, FQHCs, insurers).

•	 Reimburse for care coordination and case

 management (Medicaid, insurers).

Improving outreach and community education. 

•	 Increase awareness of asthma in low-income

 and racial/ethnic minority communities 
Appendix C 43

 through multilingual, culturally-relevant 

 awareness campaigns (NGOs and local and 

 state health departments).

•	 Develop common messages and media

 resources for local use.

•	 Increase awareness through deployment of

 community health workers/educators 

 (NGOs, local health departments).

•	 Increase awareness of asthma among

 providers of social services to low income 

 and racial/minority communities so that 

 they can make appropriate referrals 

 (local health departments).

Improving surveillance of disparities. 

•	 Report on quality and outcomes of asthma

 care by race/ethnicity, income and insurance 

 status (health providers, insurers, healthcare 

 quality organizations).

•	 Report on asthma prevalence, exposure to

 asthma triggers, urgent health services 

 utilization (ED and hospital) and access to 

 medical homes by race/ethnicity, income 

 and insurance status (local, state and 

 national public health agencies).

Improving control of environmental factors that 

affect asthma. 

•	 Provide resources for environmental

 control (e.g., bedding encasements, 

 vacuums, cleaning supplies, High Efficiency 

 Particulate Air filters) as part of comprehen-

 sive asthma education and trigger reduction 

 programs (Insurers, Medicaid).

•	 Assure access to allergy testing by

 training safety net providers in skin testing 

 or use of Radioallergosorbent Test testing 

 (HRSA, insurers, local public health).

Improving housing quality. 

•	 Provide home environmental inspections

 for low income and racial/ethnic minority 

 households (NGOs, local health 

 departments, FQHCs).

•	 Offer advice and assistance to low income

 and racial/ethnic minority households, 

 landlords and public housing agencies to 

 remediate structural problems that contrib-

 ute to increased exposure to asthma triggers 

 (NGOs, local health departments, FQHCs).

•	 Improve local housing codes so that they

 reflect current knowledge of Healthy Homes 

 building and maintenance practices 

 (local public health, local/state/national 

 housing code organizations, local housing 

 inspection agencies).

•	 Train local housing inspectors and other

 home visitors in the recognition of un

 healthy indoor environmental conditions 

 and in the procedures to refer households 

 for assistance in remediation of these 

 conditions (local public health).

Improving ambient air quality. 

•	 Locate schools and residential developments

 away from sources of ozone, particulate 

 matter, nitrogen oxides, freeways, industrial 

 sources and transportation hubs (local 

 public health, local asthma coalitions, local 

 zoning and planning agencies, local transit 

 and transportation agencies, school 

 districts).

Improving community capacity to control 

asthma. 

•	 Encourage collaborative partnerships for

local asthma coalitions to enhance their 

ability to contribute to community awareness, 

integration of services across sectors, and 

facilitating accountability for addressing 

asthma disparities. 

Akinbami LJ. The State of childhood asthma, United States, 

1980–2005. Advance data from vital and health statistics; no 

381, Hyattsville, MD: National Center for Health Statistics. 

2006.
44 National Asthma Education and Prevention Program Guidelines Implementation Panel Report

App

Abbreviations

AAP Asthma Action Plan

AHIP America’s Health Insurance Plans

AMGA American Medical Group Association

BCBSA Blue Cross and Blue Shield Association

CCM Chronic Care Model

CDC Centers for Disease Control and 

Prevention

CME Continuing Medical Education

CMS Centers for Medicare and Medicaid 

Services

ED Emergency Department

EHR Electronic Health Records

EPR-3 Expert Panel Report 3: Guidelines for 

the Diagnosis and Management of 

Asthma, 2007

ETS Environmental Tobacco Smoke

FQHC	 Federally Qualified Health Centers

GIP Guidelines Implementation Panel

HEDIS Healthcare Effectiveness Data and 

Information Set

HMO Health Maintenance Organization

ICS Inhaled Corticosteroids

IOM Institute of Medicine

MCO Managed Care Organization

MOC	 Maintenance of Certification

NAEPP National Asthma Education and 

Prevention Program

NCQA National Committee on Quality 

Assurance

NGO Non-Government Organization

NHLBI National Heart, Lung, and Blood 

Institute

PBM	 Pharmacy Benefits Manager

QI Quality Improvement
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