ALLIES AGAINST ASTHMAasthma.umich.edu/media/eval_autogen/program_reach.pdf · Allies Against Asthma 5 Program Reach Forms 5 of 8 IV. Educating Children with Asthma and/or Their Parents/Caregivers

Allies Against Asthma is a national project supported by the Robert Wood Johnson Foundation. Direction and technical assistance is provided by the National Program Office at the University of Michigan Center for Managing Chronic Disease.

ALLIES AGAINST ASTHMA PROGRAM REACH FORMS

Description Included in this document is a selection of forms that can be used to track coalition activities. The forms were developed by Allies Against Asthma for Program Reach, a web-based database used to capture data on the extent of coalition activities. Program Reach is a password-protected, site-specific tracking system used by coalition staff to enter data that describes the coalition activities conducted including the number and type of program participants, topics addressed and settings in which activities were conducted.

Development and Conditions of Use

Developed by Allies Against Asthma, 2003. The concept for Program Reach was based upon the Central California Asthma Project (CCAP) Activities Database. CCAP is a project of the San Joaquin Valley Health Consortium and the American Lung Association of Central California, Fresno, CA, and CCAP-affiliated community asthma coalitions. The Activities Database was developed for CCAP by the Department of Health Services Research, Palo Alto Medical Foundation Research Institute, Palo Alto, CA, with support from the National Heart, Lung, and Blood Institute of National Institutes of Health.

For use and/or adaptations of this document, please credit Allies Against Asthma and the Department of Health Services Research, Palo Alto Medical Foundation Research Institute.

Contact Information

Allies Against Asthma National Program Office Center for Managing Chronic Disease University of Michigan 109 South Observatory Street Ann Arbor, MI 48109-2029

Phone: 734-615-3312 Fax: 734-763-7379 E-mail: [email protected] www.AlliesAgainstAsthma.net

_____________________________________________________________________________________________________________________ Allies Against Asthma Program Reach Forms 2 of 8

I. Training Individuals who Work with Children with Asthma

Curriculum/Description: (specify) Participants:(enter number of participants) Medical Providers

Physicians Nurses Other Allied Health

Professionals Medical Office Staff Other (specify):

School-Based/Day Care/HeadStart Personnel

Administrators Engineers/Custodians Physical Education

Staff/Coaches School Nurses Teachers Day Care/HeadStart Workers Other (specify):

Others Who Work with Children with Asthma

Community Health Workers Health Educators Social Workers Community Agency Staff Community Volunteer WIC Staff After-School/Parks and

Recreation Staff Other (specify):

Number of training sessions: Number of total educational hours:

Setting where Participants Work: (check all that apply)

Clinic Head Start Emergency Department Elementary School Hospital (Non-Emergency Department) Middle/Junior High Private Medical Practice High School Day Care After-School/Parks & Rec. Preschool Health Education Center Community Based Organization Other (specify):

Topics Addressed: (check all that apply)

Asthma Basics Recognition of Asthma Emergency Case Finding Self Management Skills Medical Therapies Communication Skills Improving Environmental Conditions Tobacco Cessation Policies and Procedures Interviewing Skills

Other (specify): Curriculum/Program Period Term of Activity (check one)

° Time Limited Activity � On-Going Activity Reporting Period/Date of Activity Start Date (mm/dd/yyyy): ______________ End Date (mm/dd/yyyy): ______________ Comments:

_____________________________________________________________________________________________________________________ Allies Against Asthma Program Reach Forms 3 of 8

II. Care Coordination

Coordination Provided By: (Check all that apply) � Community Health Worker/Outreach Worker � Nurse/Public Health Nurse � Social Worker � Health Educator � Other (specify):

Coordination Provided Type: (Check all that apply) � Clinical Care � Asthma-related Educational Programs � Home-based Support � School-based Support � Social Services � Tobacco Cessation Education/Support � Advocacy � Assistance Obtaining Medications/Equipment � Assistance Enrolling / Maintaining Insurance �Other (specify):

Number of Children: Number of Children Served ______ Number of Total Contacts ______ Number of First Contacts ______ Reporting Period: Start Date (mm/dd/yyyy) _______ End Date (mm/dd/yyyy) _______ Comments:

_____________________________________________________________________________________________________________________ Allies Against Asthma Program Reach Forms 4 of 8

III. Home Visiting

Visits Conducted By: (Check all that apply) � Community Health Worker/Outreach Worker � Nurse Public Health Nurse � Social Worker � Health Educator � Other (specify): Program Focus: (Check all that apply) � Education For Example: Asthma Basics Self-management Skills Environmental Triggers Advocacy Skills � Environmental Action For Example: Environmental Assessment Smoking Cessation Distribution of Trigger Reduction Materials � Case Management For Example: Referrals Other Social Issues � Other (specify):

Age of Target Population: (Check all that apply)

0 - 5 year olds Elementary School Middle/Junior High High School Above High School

Visits Conducted: Number of Homes Visited _______ Number of Children Visited _______ Number of Total Visits _______ Number of First Visits _______ Zip Codes of Homes Visited: Reporting Period: Start Date (mm/dd/yyyy) End Date (mm/dd/yyyy) Comments:

_____________________________________________________________________________________________________________________ Allies Against Asthma Program Reach Forms 5 of 8

IV. Educating Children with Asthma and/or Their Parents/Caregivers Outside of Their Home

Curriculum: Title or Description: (specify) Topics Addressed: (Check all that apply) � Asthma Basics � Self Management Skills � Medications and Equipment � Environmental Triggers � Advocacy Skills � Peer Support � Other (specify): Setting: (check all that apply) � Day Care � Pre School � Head Start/Early Head Start � Elementary School � Middle/Junior High � High School � After-school/Parks and Recreation � Clinic � Emergency Department � Hospital (Non-ED) � Asthma Camp � Community � Other (specify): Educators: (Check all that apply) � Community Health Worker � Health Educator � Health Care Provider (Ex: Nurse) � Social Worker � Teacher �Community Volunteer �Other (specify):

Participants: Group or Individual:

° Group °Individual Number of Sessions Children with Asthma Number of Children ________ Number of New Children ________ Number of Total Educational Hours_______ Parents/Caregivers Number of Parents/Caregivers ________ Number of New Parents/Caregivers _______ Number of Total Educational Hours_______ Period and Location of Activity: Term of Activity: (check one)

° Time Limited Activity °On-Going Activity Reporting Period: Start Date (mm/dd/yyyy) __________ End Date (mm/dd/yyyy) __________ Zip Codes: Comments:

_____________________________________________________________________________________________________________________ Allies Against Asthma Program Reach Forms 6 of 8

V. Actions to Improve Physical Environmental Conditions within Institutions

Setting: (choose one)

° Day Care

° Preschool (Non-Head Start)

° Head Start/Early Head Start

° Elementary School

° Middle/Junior High

° High School

° After-School/Parks and Recreation

° Housing

° Community

° Other (specify): Topics: (check all that apply) � Environmental Assessment � Mold/Spore Reduction � Pest Management � Dust/Air Allergen Reduction � Other (specify):

Date and Location of Activity: Reporting Period: Start Date (mm/dd/yyyy) ________ End Date (mm/dd/yyyy) ________ Zip Codes: Comments:

_____________________________________________________________________________________________________________________ Allies Against Asthma Program Reach Forms 7 of 8

VI. Quality Improvement

Systems Involved (provide numbers) ____ In-Patient Hospital ____ Emergency Department ____ Primary Care Physicians ____ Specialists ____ Clinic ____ MCO/Insurer ____ School ____ Daycare/Preschool/Headstart ____ Home Visiting Program ____ Community Based Organization ____ After-school/Parks and Recreation ____ Other (specify):

Target Population/Participants: (provide numbers for all that apply) ____ Physicians ____ Nurses ____ Educators ____ Clerks/Administrative Personnel ____ Other (specify):

Breadth of Activity (optional) ____ Number of Charts Audited/Abstracted ____ Number of Incentives Provided ____ Number of Participants Provided Feedback on Performance ____ Other (specify): Reporting Period Start Date (mm/dd/yyyy) _______ End Date (mm/dd/yyyy) _______ Describe/Comments:

_____________________________________________________________________________________________________________________ Allies Against Asthma Program Reach Forms 8 of 8

VII. General Community Awareness Activities

Activities: (complete all that apply) Community Events (enter number of activities) _____ Health Fairs _____ Community Forum _____ Fundraisers _____ Approximate Total Number of Participants Presentations (enter number of activities) _____ General Asthma Presentations _____ Presentations about the Coalition _____ Approximate Total Number of Participants Media Campaigns (enter number of activities) _____ Number of Newspaper/Magazine Stories _____ Number of TV/Radio Stories _____ Number of Billboard, Bus or Posters Mounted Other Community Events (enter number of activities) _____ Theater Production _____ Other (specify): Environmental Actions (Describe:)

Reporting Period: Start Date (mm/dd/yyyy): _________ End Date (mm/dd/yyyy): _________ Comments: