Section VIII: Sample Documents and Materials
Sites developed a number of different approaches to the ICAI intervention. Descriptive materials, data forms, outreach and buy-in efforts and other aspects of implementation were generally site-specific. Some of the documents and materials used at the sites may be helpful to organizations contemplating development of an asthma management project.
I. Physician, Organization and Community Buy-in
Community Buy-in Brochure
This is an excellent example of how an organization participated in coordinated regional care in their
Physician Buy-in Letter
This site developed a series of letters to engage the patients primary care physician (PCP) in the intervention and to promote teamwork. The three sampled below demonstrate the sites commitment to by-in.
- Notification Letter- The initial letter thanks the physician for referring the patient, reiterates the purpose of the program and reinforces the need to work together.
- Progress Report- Periodically, a progress report is placed in the patients chart to keep the physician abreast of the areas that were reviewed, note possible issues or areas of concern, and patient improvements.
- Completion Letter- The final letter is sent to the PCP upon the familys completion of the intervention. It discusses strengths and makes recommendation(s) to help promote compliance.
II. Outreach/Marketing/Recruitment/Referral
Outreach Chart
This chart was designed by an asthma counselor to chronicle the outreach efforts made in the local community.
Outreach Marketing Brochure
This brochure is colorful, informative and was placed in the offices of pediatric PCPs to inform their patients about the asthma program.
Outreach Marketing Brochure (2)
This site had a significant Spanish-speaking client base, so they designed their brochure to accordion fold into a two-page English/Spanish pamphlet.
Referral Form
This general referral form was used to capture in-house recruitment/referrals and track where they originated. The form the gathers basic information needed to determine patient eligibility and contact the patient/family.
III. Risk Assessment
CARAT (Child Asthma Risk Assessment Tool)
The CARAT format was developed by NCICAS designers to be used as the standardized tool to identify four problem areas that might require intervention: access to primary care for asthma, adherence, behavior, and environment.
IV. Enrollment
Enrollment Letter
This notice was sent to newly recruited families. Its purpose was to share contact information, reinforce topics discussed at enrollment and to inform the families of when and where they were scheduled to attend sessions. Included with this letter was a map of the site and room location where group sessions were held.
English-Spanish Enrollment Letter
This letter was used to contact families newly recruited into the intervention. English and Spanish versions were made available to provide a reminder to the family of their commitment to participate in the intervention, send a message of encouragement and provide contact information.
Enrollment Agreement
This form letter gives families all the basic information about the program, their responsibilities, the time commitment required, and calls for them to sign an agreement to show that they are willing to participate.
V. Asthma Action Plans
State Asthma Action Plans
The Commonwealth of Massachusetts makes statewide templates available for asthma management plans in English*, Spanish*, Portuguese, Haitian, Creole, Russian*, Chinese, Khmer and Vietnamese* based on NIH guidelines (*= sample included).
Asthma Action Plans
This is an example of another asthma plan template available in English and Spanish. It differs slightly from the previous format, but conveys all of the important asthma management information.
AAFA Student Asthma Form
This form was developed by the Asthma and Allergy Foundation of America. It was shared with the families to help support the child with asthma by organizing pertinent information about the childs asthma needs and how to manage the condition for the school setting.
VI. Intervention Follow-up/Data Collection
Follow-up and Data Forms
This site created forms that were the basis for uniform follow-up and data collection.
- Health Survey- Collected a variety of medical information from the family on a monthly basis. The form allows for explanation of reasons for progress or lack of progress, and valuable information about a family.
- Participant Satisfaction form- Post enrollment questions that helped determine areas for improvement in the program and quantify improvement the child and familys management of asthma from their perspective.
Data Collection Forms
These forms were all geared to data collection and are examples of forms that work on multiple-levels. They helped the asthma counselor track the familys progress, updated file information and collected useful data for future need.
- Intake form- Used to collect needed information at enrollment.
- Monthly Session form- Addressed uniform follow-up for each child and family, tracked progress in managing the childs asthma and is set-up for convenient data retrieval and entry.
- Project Completion form- Used to track patient progress and to assemble follow-up information.
Participation Inquiry Letter
This form letter was used to inquire about a familys interest in continuing their participation in the intervention.
VII. Program Management
ICAI Site P&P Manual
This asthma team created a formal policy and procedure manual for the asthma program. Excerpts from the manual include the Table of Contents, a list of folders and descriptions, the marketing and outreach approach and guidelines for dealing with referrals.
VIII. Other Materials:
"A Guide for Helping Children With Asthma"
Appendix
The
- American Lung Association of MN,
- Baystate Medical Center Childrens Hospital,
- CareOregon,
- Childrens Asthma Consortium,
- Childrens
- Childrens
- John J. Stroger, Jr
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