December 18, 2007

Strategic Plan:

A Road Map for the Future
January 1, 2008

BACKGROUND:

In May 2000, the Regional Directors of the New England Region I offices of the U.S. Department of Health and Human Services (DHHS), the U.S. Environmental Protection Agency (EPA), and U.S. Department of Housing and Urban Development (HUD) hosted a summit of New England State Commissioners of Environment, Public Health, Housing, and Education to address the challenges posed by the growing pediatric asthma epidemic. The Summit’s purpose was to encourage inter-governmental and multi-disciplinary partners in the region to commit to working together on the environmental aspects of the disease, since there was already attention being paid to its clinical dimensions through the New England Public Health and Managed Care Collaborative and the health care sector in general. The federal and state leaders envisioned an inter-governmental collaboration which would diminish the “silo” effect of agencies and states working separately on the issue, encourage the sharing of emerging best practices and evidence-based policies, and efficiently and effectively improve childhood asthma outcomes in New England.

Summit attendees called for three priority actions to address asthma:
• the establishment of a regional coordinating council,
• the launching of a regional asthma tracking initiative, and
• the creation of guidance for the design, renovation and maintenance of asthma friendly schools and homes.

Thus the Asthma Regional Council (ARC) was first convened on November 1, 2000. Through ARC, multidisciplinary leaders with knowledge, resources and determination joined forces to swiftly identify and implement solutions to this growing public health epidemic through expanded application of innovative models and linkages to a larger network of potential partners.

In the first years, the Council developed a Mission Statement and an Asthma Action Plan, both of which have been refined over the years.

MISSION:
ARC works to reduce the impact of asthma across New England through collaborations of health, housing, education, and environmental organizations, with particular focus on the contribution of schools, homes and communities to the disease and with attention to its disproportionate impact on populations at greatest risk.

ACTION PLAN:
The Asthma Action Plan identified four targeted areas for action that are within the control or influence of Council members: Surveillance, Outreach and Education, Exposure Reduction in Homes and Schools, and Exposure Reduction in the Community, and these four broad areas contained 12 specific priority action items. Action items were designed to allow individual states the greatest flexibility in designing the means of achieving these objectives, with the expectation that agencies would experiment and innovate to meet these policy targets.

THE ORGANIZATION:
ARC is comprised of federal, state and large municipal agency leaders, along with select NGOs and academic partners who help to inform its direction. The organization was not intended by its founders to exist permanently; rather it was established to stimulate collaborations primarily among federal and state agencies, and to tackle “the low hanging” fruit that could rapidly make a difference in asthma outcomes.

In 2002, ARC became formally affiliated with The Medical Foundation (TMF), a 501(c)3 non-profit public health and medical research funding organization. TMF’s mission is to help people live healthier lives and create healthy communities through prevention, health promotion, and research. Since then, ARC has been staffed by a part-time Executive Director, a part-time Programs Coordinator, and a number of highly effective consultants who specialize in the environmental public health arenas in which ARC engages. While the Executive Director reports administratively to the Vice President of Community Health at TMF, an Executive Committee, consisting of Council members, was appointed to help guide the Executive Director in the programmatic direction of the organization. Ongoing communications and decisions are also conducted through ARC’s subcommittees, consisting of Healthy Homes, Healthy Schools, Diesel Reduction, Asthma Surveillance, and Environmental Investments in Health Care.

Beginning with a budget of nearly $80,000 in 2002, ARC’s annual budget blossomed to nearly $400,000 through effective fundraising strategies. In addition, the Council membership has grown from approximately 40 high-level policy makers, to a more diverse membership of over 100 individuals that work in state and municipal agencies on asthma, and their partners. At this time, an aggressive fundraising plan needs to be in place to continue operations.

STRATEGIES AND ACCOMPLISHMENTS:

ARC, through its partners, accomplished a great deal in its first seven years of existence. During that time, the evidence base concerning the environmental aspects of the disease was just emerging. Thus, a good deal of ARC’s emphasis during this period was to rapidly disseminate-and encourage the adoption of- best practices, tools, and model programs that showed promise for making rapid and successful gains. A number of policy papers, educational programs and resources, technical assistance and research opportunities, communication mechanisms, and partnerships were developed to facilitate the rapid sharing of information and adoption of ARC’s Asthma Action Plan. ARC worked hard to successfully encourage states to adopt policies and programs that have made a difference for asthma sufferers across the region. Moreover, to communicate these developments readily and broadly, ARC created a website and newsletter, Innovations. Both resources are full of local and national information on asthma.

In addition, ARC raised the region’s understanding and awareness about the disease through launching a first-of-its-kind coordinated asthma surveillance initiative. In 2001, when ARC formally constituted, some of the states were only beginning to track asthma prevalence, but utilized different data sources and tracking mechanisms to do so. It was therefore difficult to compare trends over time, and have a meaningful understanding of how asthma was manifesting itself across our six New England states. To that end, we coordinated the six state health surveillance staff to work with ARC on compiling the data in a unified effort, and creating a coordinated set of recommendations based on the findings, in two comprehensive reports released in 2003 and 2006. These reports received widespread media and policy attention.

ARC can be proud that many of the 12-point action items that it developed seven years ago are now being tackled by the states, to the extent that their resources permit. Further, with the leadership of the states’ CDC-funded Asthma Programs, many of the states’ agencies in health, education, housing and environment are actively collaborating together to address asthma on the local level. However, there is still widespread frustration that a dearth of resources hinders the implementation of programs more widely.

CONTINUED BASIS FOR ACTION:

Over time, there have been a number of observations and conclusions that have been gleaned from ARC’s surveillance efforts, through structured interviews with our partners, as well as through relevant emerging research and practice that are important to informing ARC’s work now and into the future:

a) The New England region continues to have among the highest rates of both childhood and adult asthma prevalence in the country, with one in seven adults and children having been given a diagnosis of asthma in their lifetimes;

b) Economic and racial disparities exist, with low income families and Latino and Black communities bearing the heaviest burden of the disease;

c) The region’s asthma prevalence rates continue to rise significantly;

d) Based on sheer numbers, many more adults have asthma than do children. As a result, our mission has expanded from exclusively addressing pediatric asthma to addressing all age groups, with a focus on disadvantaged populations;

e) Best practices for effective asthma management need wider adoption and insurance reimbursement; and these programs need to address both the clinical and environmental aspects of the disease in a complementary manner;

f) Asthma shares many features with other chronic diseases, such as the need for disease management services and the provision of community-based care and education in order to be effective;

g) ARC has been successful in fostering collaborations and communications between multi-sector agency partners, but a new set of bureaucratic barriers need to be addressed. In particular, Chronic Disease and Healthy Homes Programs—often housed within public health departments-- frequently share high risk populations and common interventions, but sometimes operate with little collaboration between and among each other. By fostering interaction and common planning between these programs, a more efficient and effective approach to health promotion can be realized;

h) Recent research points to the following environmental conditions that relate most conclusively to asthma incidence, prevalence and/or exacerbation in the Northeast: smoking and ETS, small particulates (including wood smoke and chemical fragrances), cockroaches and mice, cats, and mold. By focusing our efforts on these contributors, we can influence asthma outcomes to the greatest degree;

i) The New England Public Health and Managed Care Collaborative no longer exists as a separate entity; ARC has been requested to carry on its work on the clinical aspects of asthma to whatever extent possible;

j) Access to complete health data is still lacking in much of the region, which limits our collective ability to track asthma accurately and link health status to environmental indicators. This is primarily because much of the outpatient data is owned by private insurers and therefore proprietary -- and, thus, usually not shared with public health partners. Further, public health partners frequently lack the resources to analyze and report the data. Current data sources, such as the BRFSS and hospital discharge data, are limited in terms of their ability to fully describe the asthma epidemic, but they are some of the best uniform sources we currently have as a region. The region continues to need access to high quality, uniform data sets in order to improve our understanding of asthma trends, and focus our limited resources on appropriate care and populations most in need.

ACTION STRATEGIES:

In the updated plan, ARC would focus primarily on the following:

o Coordination of regional activities
o Convening of stakeholders and partners
o Promoting best practices and policies
o Providing targeted technical assistance, education, and program implementation
o Tracking of disease status across the region
o Keeping environmental public health (esp. asthma) on the radar screens of policy makers
o Bringing new opportunities and resources to the region

ARC’s Roadmap (January 1, 2008):
To address the emerging needs, research and knowledge before us after seven years in business, ARC’s leadership felt it was time to significantly update its New England Asthma Action Plan for the region. This new Action Plan was developed after convening 3 strategic planning meetings of Council members and leaders across the region over the last 9 months—in addition to conducting structured interviews with the state Asthma Coordinators. It reflects their input and the current scientific evidence base to date on the epidemic.

The Strategic Planning process was facilitated by professionals from the EPA and Future Management Systems, who worked with ARC’s executive committee, representatives from HUD and the EPA, and a state asthma manager to formulate a new Asthma Action Plan for New England. The process began with a meeting on March 30, 2007, when we invited 60 New England partners to discuss whether it made sense for there to be a continued Asthma Regional Council, and to brainstorm areas where we might focus our efforts in the future. The meeting participants articulated a broad consensus that there was a continued need for ARC to exist. Then on August 23rd, 2007, we invited a smaller group of leaders across the region to join ARC’s Executive Committee to help hone the many excellent suggestions we received at our meeting in March. Finally, on November 2nd, the original strategic planning committee finalized the new Asthma Action Plan, which is presented below.

ARC will continue to emphasize all aspects of improving both the indoor and ambient environment that impacts asthma. However, the following significant philosophical shifts are reflected in the Action Items:
a) Because asthma continues to be a poorly controlled epidemic, ARC will set out to improve both the environmental and clinical aspects of the disease
b) ARC will address both pediatric and adult populations
c) ARC will continue to encourage comprehensive collaborative approaches to promoting environmental health in the region by addressing other public health issues (e.g., chronic diseases) and home-based interventions (e.g., lead, injury prevention, radon) that share commonalities with asthma.

GUIDING PRINCIPLES:
• Coordination of the efforts of the New England federal and state governmental agencies is advantageous for an effective response to the asthma epidemic
• ARC will focus on improving asthma outcomes by addressing both the environmental and clinical management aspects of the disease, and by paying attention to primary prevention efforts as well
• Evidence-based actions will be promoted; however experimentation with innovative models will be valued should they hold reasonable promise for reducing the impact of asthma and improving public health
• Partnerships with community-based, health care and academic institutions are encouraged
• Priority will be given to programs that benefit vulnerable populations
• ARC will add to the understanding of asthma in New England through evaluation of the efficacy and cost effectiveness of our policy and programmatic actions
• Dissemination and advocacy for adoption of successful strategies and policies in the region will be an ongoing emphasis of our work
• ARC’s Action Plan is meant to be a broad road map for the region. The organization cannot dictate state actions, but the action items will be adopted and supported to the best of states’ abilities. In addition, to the extent possible, states will attempt to coordinate with ARC, and financially support its continuation, whenever feasible.

NEW ENGLAND ASTHMA ACTION PLAN

In keeping with these guidelines, the following New England Asthma Action Plan will be pursued by ARC in collaboration with its state and local partners. The plan is not meant to limit states’ activities to these areas alone, but rather it seeks to promote focus areas that reflect evidence-based best practices, that are within ARC’s purview and capacity, and where there is an identified new or continued need:

Action Area 1: Promote Best Practices and Policies which Foster Excellence in Environmental and Clinical Asthma Management:

Focus Area 1: Proactively disseminate guidance, models and resources for providers to adopt quality care that integrates clinical, educational and environmental components
Focus Area 2: Promote a public health approach to asthma, working with state and local health departments to increase states’ capacity to supplement clinical care with community-based and home-based services
Focus Area 3: Promote updated national NAEPP asthma care guidelines, and advocate for alignment of health care reimbursement of quality standards
Focus Area 4: Promote the “business case” to health care payers for educational and home-based environmental services to improve asthma outcomes
Focus Area 5: Promote integration of asthma services with other chronic disease management programs, to improve efficiency and effectiveness

Action Area 2: Promote an Integrated and Broad-based Healthy Homes Agenda

Focus Area 1: Promote policies, programs, and education that foster asthma-friendly environments and reduce exposure to ETS, mold, pests and chemicals
Focus Area 2: Work with state agencies and community organizations to encourage the integration and coordination of their Healthy Homes programs (asthma, lead, injury protection, radon, CO, weatherization programs)
Focus Area 3: Continue promoting adoption of ARC’s updated Healthy Homes Building and Property Maintenance Guidance.

Action Area 3: Increase Access to, as well as Analysis and Application of, High-quality Health Data:

Focus Area 1: Collaborate with states to continue periodic asthma surveillance on a regional basis- using the best data available, including school data-- and produce reports of findings and recommendations for action
Focus Area 2: Strive to produce periodic “Environmental Health Integration Reports” on the status of chronic diseases (including asthma) in the region that are influenced by environmental factors, helping to put asthma in a chronic disease context, while highlighting shared risk factors such as tobacco, particulates, and toxic chemicals.
Focus Area 3: Promote the availability of comprehensive health information repositories in states to foster access to, and analysis of, the best data available (both public and proprietary) on a timely basis, and ensure that this data is used to promote the public’s health

Action Area 4: Support Improvement of Indoor and Ambient Air Quality

Focus Area 1: Promote reduction of exposure to pests and rodents, mold, wood and environmental tobacco smoke, and toxic chemicals in residences, schools, buildings, and workplaces
Focus Area 2: Develop and disseminate guidance document for planners on near roadway residences and buildings which house children (e.g., schools and daycare facilities)
Focus Area 3: Support the work of ASTHO and its state environmental health directors to develop and promote model indoor air codes