The Merck Childhood Asthma Network, Inc. (MCAN)

Transcription

Health Promotion
Practice
http://hpp.sagepub.com/
Translating Evidence-Based Interventions Into Practice : The Design and Development of the Merck
Childhood Asthma Network, Inc. (MCAN)
Meera Viswanathan, Linda Lux, Kathleen N. Lohr, Tammeka Swinson Evans, Lucia Rojas Smith, Carol Woodell, Carol
Mansfield, Niamh Darcy, MCAN Site Investigators, Yvonne U. Ohadike, Julie Kennedy Lesch and Floyd J. Malveaux
Health Promot Pract 2011 12: 9S
DOI: 10.1177/1524839911412594
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HPPXXX10.1177/152483991
1412594Viswanathan et al. / Design And Development Of The Merck Childhood Asthma NetworkHealth
Promotion Practice Month XXXX
Translating Evidence-Based Interventions
Into Practice: The Design and Development
of the Merck Childhood Asthma
Network, Inc. (MCAN)
Meera Viswanathan, PhD1
Linda Lux, MPA1
Kathleen N. Lohr, PhD1
Tammeka Swinson Evans, MOP1
Lucia Rojas Smith, DrPH, MPH1
Carol Woodell, BSPH1
Carol Mansfield, PhD1
Niamh Darcy, MS1
MCAN Site Investigators
Yvonne U. Ohadike, PhD2
Julie Kennedy Lesch, MPA2
Floyd J. Malveaux, MD, PhD2
Pediatric asthma is a multifactorial disease, requiring
complex, interrelated interventions addressing children,
families, schools, and communities. The Merck Childhood
Asthma Network, Inc. (MCAN) is a nonprofit organization that provides support to translate evidence-based
interventions from research to practice. MCAN developed the rationale and vision for the program through a
phased approach, including an extensive literature
review, stakeholder engagement, and evaluation of funding gaps. The analysis pointed to the need to identify
pediatric asthma interventions implemented in urban
U.S. settings that have demonstrated efficacy and materials for replication and to translate the interventions into
wider practice. In addition to this overall MCAN objective,
specific goals included service and system integration
through linkages among health care providers, schools,
community-based organizations, patients, parents, and
other caregivers. MCAN selected sites based on demonstrated ability to implement effective interventions and
Health Promotion Practice
November 2011 Vol. 12, Suppl. 1, 9S–19S
DOI: 10.1177/1524839911412594
© 2011 Society for Public Health Education
to address multiple contexts of pediatric asthma prevention
and management. Selected MCAN program sites were
mature institutions or organizations with significant infrastructure, existing funding, and the ability to provide services without requiring a lengthy planning period. Program
1
RTI International, Research Triangle Park, NC, USA
Merck Childhood Asthma Network, Inc., Washington, DC, USA
2
Authors’ Note: MCAN site investigators include Tyra BryantStephens, MD, The Children’s Hospital of Philadelphia, Philadelphia, PA; Marielena Lara, MD, MPH, RAND Health, Santa Monica,
CA; Adriana Matiz, MD, Columbia University, New York, NY; Victoria W. Persky, MD, University of Illinois at Chicago, Chicago, IL;
Kimberly Uyeda, MD, MPH, Los Angeles Unified School District,
Los Angeles, CA; and Rhonda Williams, MES, Respiratory Health
Association of Metropolitan Chicago, Chicago, IL.
Supplement Note: This article is published in the supplement
“Translation of Evidence-Based Pediatric Asthma Interventions
in Community Settings: The MCAN Experience” supported by an
educational grant to SOPHE from the Merck Childhood Asthma
Network, Inc. (MCAN), a nonprofit 501(c)(3) organization. MCAN
is funded by the Merck Company Foundation.
9S
sites were located in communities with high asthma morbidity and intended to integrate new elements into existing
programs to create comprehensive care approaches.
Keywords: asthma; chronic disease; health disparities; lay health advisors; community
health workers; partnerships/coalitions;
community intervention
Background
>>
Asthma in Children
In 2005, the Merck Company Foundation initiated a
multisite, national program to address the growing
problem of childhood asthma by funding the Merck
Childhood Asthma Network, Inc. (MCAN). Asthma is a
chronic condition for which no treatment has been
shown to be curative. It is a multifactorial disease influenced by allergenic, climatic, environmental, infectious, and emotional triggers. The overall goal of asthma
management is to prevent or minimize symptoms, eliminate or reduce exposure to triggers, and limit adverse
effects of therapy (Aronson et al., 2001).
Asthma is a significant public health problem in the
United States, particularly among children. Almost 7 million children (10% of the U.S. population) younger than
18 years have asthma (Bloom, Cohen, & Freeman, 2009).
It accounts for half a million hospitalizations each year
(Bloom et al., 2009) and is the leading diagnosis for inpatients aged 1 to 17 years (Levit, Wier, Stranges, Ryan, &
Elixhauser, 2009). The disease costs the nation (in direct
medical and indirect costs) approximately $19.7 billion
annually (American Lung Association, Epidemiology
andStatistics Unit, & Research and Program Services,
2007). Childhood asthma also contributes to missed
school days and missed work days for caregivers. Asthma
is a very common health-related cause of school absenteeism, accounting for nearly 13 million missed school days
in 2003 among the nearly 4 million children who reported
at least one asthma attack in the preceding year (Akinbami,
2006). African American and Puerto Rican children suffer
disproportionately higher rates of hospitalizations and
death associated with asthma than children of other races
or ethnic backgrounds (The Asthma and Allergy
Foundation of America & the National Pharmaceutical
Council, 2005; Bloom et al., 2009).
From 1980 to 1996, asthma prevalence among children increased by an average of 4.3% per year, from
3.6% to 6.2% (Mannino et al., 2002). In recent years, asthma
prevalence and exacerbation rates have remained relatively steady (Akinbami, Moorman, Garbe, & Sondik, 2009).
Despite overall declines in asthma-related mortality and
hospitalizations, low-income and minority populations
and children living in inner cities continue to experience
disproportionately higher morbidity and mortality
from asthma compared with other children (Akinbami
et al., 2009).
Asthma Interventions
The range of interventions for asthma, particularly
for children, is extremely diverse. Preventive and therapeutic steps include
• avoiding triggers (including eliminating those that
occur in the patient’s immediate environment, such
as parental smoking or allergens),
• selecting from an array of medications to control
asthma symptoms and to minimize airway inflammation, exacerbations, and adverse reactions,
• educating patients and families about this chronic
disease and about self-management strategies,
• mounting educational programs for stakeholders in
asthma care (e.g., primary care clinicians, schoolbased personnel, and social service providers),
• initiating care management and/or environmental
trigger mediation programs,
• carrying out social media campaigns, and
• implementing a wide array of community-based or
policy-oriented activities.
Typically these steps and programs have been developed independently and are not routinely integrated.
Effective asthma care improves the quality of life for children who have asthma and their families. Domains of
interest in improved quality of life include physical functioning, emotional well-being, and participation in ageappropriate school, social, and play activities. Effective
programs to reduce the burden of asthma among children
require, therefore, a comprehensive approach that encompasses medical care, behavioral and lifestyle modification, educational services, housing, environmental
reforms, and other community services (Lara et al., 2002).
The Expert Panel Report 3 of the National Asthma
Education and Prevention Program (NAEPP) highlights
four core components: assessment and monitoring of
diagnosis, severity, and control of asthma; education for a
partnership in asthma care; control of environmental factors and comorbid conditions that affect asthma; and
pharmacologic therapy (U.S. Department of Health and
Human Services, National Institutes of Health, & National
Heart, Lung, and Blood Institute, 2007). Interventions that
demonstrate greatest improvements in outcomes are
based on theoretical frameworks, are of relatively long
duration, and use combinations of educational modalities
10S HEALTH PROMOTION PRACTICE / November 2011
(Bravata et al., 2007). A comprehensive approach to
asthma management suggests the need for integrated
interventions to ensure patient-centered care.
The remainder of this article describes the steps
taken to initiate a major national asthma initiative that
builds on existing evidence to translate it into practice.
It outlines the objectives of the initiative; describes the
process of formulating a vision through interviews with
key experts, a review of the literature, and identification of promising interventions; describes the selection
of the initiative’s sites; documents key characteristics
of the sites; and offers some concluding thoughts that
may assist researchers, health care providers, community
organizations, and policy makers to translate evidencebased interventions in specific communities and health
care systems. Other authors in this supplement describe
the evaluation (Viswanathan et al., 2011), interventions
(Findley et al., 2011), outcomes (Mansfield et al., 2011),
and partnerships (Rojas Smith et al., 2011) of the initiative.
Next Steps in Asthma Care
>>
In developing the “next generation” of interventions
to improve the quality of and access to asthma care for
children of all ages, key considerations for the Merck
Company Foundation included the comprehensiveness
of the approach, potential for significant public health
impact, unique value for the nation, and the potential
for community collaborations to enhance sustainability. Asthma experts suggested that the Foundation
choose one of three options: (a) support the expansion
and integration of existing programs focused on childhood asthma, (b) develop and test new interventions,
or (c) evaluate existing interventions with significant
promise. These experts agreed that several effective
asthma interventions existed at that time; however,
they emphasized that efforts to that point had not
focused on integrating and translating such interventions into a comprehensive program.
An integrated approach worked well with the Merck
Company Foundation’s interest in involving communities in providing comprehensive care. Furthermore, the
Foundation wanted to support improvements in asthma
care (and outcomes) per se, not fund purely research
efforts. Thus, the Foundation preferred to build on
existing knowledge rather than develop and test new
programs. Foundation leadership intended for MCAN
to create a strong independent presence in asthma care
for children, as a separate 501(c)(3) organization, and
evaluating promising programs alone would not serve
this particular purpose.
For all these reasons, the Foundation chose evidencebased, community-centered, comprehensive models of
asthma care as the driving theme, one in keeping with
a well-known set of attributes promulgated in a Robert
Wood Johnson Foundation report (Lara et al., 2002).
The Foundation commissioned RTI International
(RTI) to identify a theoretical framework, find promising interventions for translation into practice, and
conduct interviews with scientific experts to help
develop the call for proposals, mission, and objectives
for MCAN.
Theoretical Models for Care of Chronic Conditions
Having evaluated several theoretical models, RTI
determined that the model that served as the best fit for
MCAN’s objectives was the expanded chronic care
model (ECCM, Figure 1; Barr et al., 2003). The ECCM
focuses primarily on changes in the health care system,
supported by complementary changes in policy, community, and the environment. It identifies the essential
elements of a health care system that foster disease
prevention and health promotion and encourages highquality chronic disease care. The ECCM places all the
elements within the broader context of the community,
of which the health care system is a part. When the
health care system is organized effectively and efficiently, it can create a culture, organization, and mechanisms that promote safe, high-quality care. The
community can support this effort by mobilizing community resources to meet needs of patients.
The ECCM approach suggests that significant gains
in asthma care cannot be achieved without initiating
and supporting change at several different levels. As
suggested by Stokols (1996), successful interventions
should enhance the fit between people and their surroundings, by considering joint influences of intrapersonal and environmental conditions. Successful
interventions need focus on high-impact behavioral
and organizational “leverage points.” This means that
places and environments in which a behavior is most
likely to occur can play a crucial role in influencing
that behavior. The ECCM appropriately reflects the
complexities of improving care management for asthma
patients, and it served as the underpinning for the
MCAN initiative’s goals and as a framework to evaluate
promising interventions for translation.
Expert Opinions About Pediatric Asthma Care
RTI identified and interviewed 15 national experts
in pediatric asthma. Before the interviews, RTI developed a semistructured protocol designed to solicit
individuals’ opinions in four areas:
Viswanathan et al. / DESIGN AND DEVELOPMENT OF THE MERCK CHILDHOOD ASTHMA NETWORK
11S
FIGURE 1 Expanded Chronic Care Model
SOURCE: Barr et al. (2003). Reprinted with permission.
• perceived gaps in development of pediatric asthma
interventions and program delivery and what is
needed to close that gap,
• components they believe are essential for a successful asthma program,
• existing programs or interventions that show promise,
and
• evaluation of effectiveness considerations.
The team also asked experts to identify other individuals in this field with whom to speak about the proposed
initiative. In all, the 15 experts interviewed represented
perspectives from government (the Centers for Disease
Control and Prevention; the National Heart, Blood and
Lung Institute; state government), academia (pediatrics, public health, medicine, health policy, and health
administration), and experts on evaluation. Those
interviewed suggested that inclusion of both community and health systems in a comprehensive manner
are critical to creating successful asthma care. Regarding
community engagement, the analysis found that comparatively few interventions at the time focused on
building public policy and creating community action.
Experts concurred that both of these components
were required to ensure successful asthma programs. Regarding health system components, the analysis found that comparatively few interventions focused
on providing decision support or integrating clinical
information systems at the time. Experts did not generally focus on integrating clinical information systems,
but they concurred that a major gap in asthma related
to the quality of care delivered by providers. They also
focused on the issue of decision support, particularly
with regard to the incorporation of NAEPP guidelines
in asthma management. These findings influenced further development of the initiative through the criteria
applied when reviewing the literature to find evidencebased interventions.
Promising and Evidence-Based
Interventions in Pediatric Asthma Care
To identify promising and evidence-based interventions, RTI staff carried out an extensive review of the
published literature, websites, and other materials and
used information from the expert interviews. First, the
team applied inclusion/exclusion criteria to a search (in
September 2004) of MEDLINE® and the Cochrane Library.
Completed evaluations using randomized controlled trials (RCTs) were included. Ongoing studies, purely
pharmacotherapy-related or genetic research studies, or
studies based on designs other than RCTs were excluded.
Second, the RTI staff hand-searched reference lists of
articles that were retained for review and data abstraction. Third, the staff searched web-based sources such
as the list of potentially effective interventions maintained by the Centers for Disease Control and Prevention
(http://www.cdc.gov/asthma/interventions/default.htm).
Fourth, experts identified promising interventions that
were not found by other means.
The RTI staff evaluated interventions, first, to determine their efficacy (i.e., demonstrated improvement in
health outcomes), second, to document the breadth of
their reach (i.e., whether they addressed components of
the ECCM), and third, to evaluate their replicability.
The team was guided by expert input in seeking interventions that addressed both community and health
systems. The analysis of interventions suggested that
relatively few integrated or coordinated comprehensive
interventions existed at that time. Single-component
programs are older than multifaceted ones and are,
therefore, more likely to have been evaluated. Multifaceted
programs and broadly comprehensive interventions
reflected changes in thinking about addressing multiple issues in asthma care and were newer than singlecomponent interventions; in particular, these interventions
had not tested the relative contributions of their components to effectiveness. Interventions that focused
solely on the community were all relatively new; none
to date had been evaluated in its entirety at the time of
the evaluation.
For effective interventions with multiple components, the authors also evaluated the settings in which
these interventions could be replicated or implemented; organizational structure needed for effective
implementation; potential for sustainability; costs; and
whether toolkits, educational packets, or other materials
were available for others to use. Several effective interventions had materials and protocols for replication;
some made such materials available free of charge, and
others charged a fee. Some interventions appeared to
require little or no modification; the level of modification needed was unclear for others.
At the time of the release of the MCAN call for proposals in 2005, 12 promising interventions with materials for replication had been identified. Table 1 briefly
describes each one.
Translation Of Evidence
>>
Into Practice
MCAN Goals
Based on expert interviews, literature review, and
discussion with an expert planning team, MCAN designed
an initiative aimed at taking the latest asthma research
evidence into practice. With the initiative, MCAN sought
to address current challenges in childhood asthma management and care. Specifically, MCAN aimed to promote efficient integration of programs and interventions
to create asthma-friendly communities and to reduce
persistent disparities in childhood asthma morbidity
and mortality. MCAN also sought to integrate evidencebased interventions into community-based programs
and local health systems, as suggested by the experts the
RTI team interviewed. Consequently, MCAN supported
innovative, comprehensive, evidence-based program
models that linked a community-based approach to quality clinical care among stakeholders to improve health
and asthma-related outcomes.
The MCAN initiative recognized the complex and
multifactorial nature of asthma. It went beyond improving asthma treatment for the individual child to initiating and supporting changes in health care systems,
families, organizations, institutions, community, and
public policy.
MCAN initiated programs in 2005 with six longterm goals. The first three goals describe institutional
goals, the fourth and fifth reflect the innovative processes espoused by MCAN, and the sixth outlines longterm objectives. MCAN goals espoused were to
1. function as a leader and advocate for high-quality
health care for children with asthma in the United
States;
2.support and rigorously evaluate evidence-based
childhood asthma programs through translational
research in selected communities around the
country;
13S
TABLE 1
Evidence-Based Pediatric Asthma Interventions for Replication
Asthma Care Training (ACT) for Kids: Delivered in a clinic setting, this asthma education and self-management
intervention is for children with severe asthma between the ages of 7 and 12 years, as well as for their parents. ACT
aims to increase knowledge, confidence, and skills to reduce the frequency of asthma attacks; it is intended to
supplement existing medical care (Lewis, Rachelefsky, Lewis, de la Sota, & Kaplan, 1984; Rachelefsky, Lewis, de la
Sota, & Lewis, 1985).
Comprehensive School-Based Asthma Program (OAS+): A more comprehensive Open Airways for Schools intervention
(see below) that is targeted to children in Grades 2 to 5, parents, classmates, and school personnel to encourage and
enable disease management (Clark et al., 2004).
Creating a Medical Home for Asthma: Provider education that encourages public health clinics to implement a teambased approach to pediatric asthma management and care. This intervention teaches communication strategies and
ways to deliver effective asthma treatment based on the National Asthma Education and Prevention Program
guidelines. (D. Evans et al., 1997)
Inner-City Asthma Study (ICAS): An individualized environmental intervention that is focused on improving the
home environment by educating families of children 5 to 11 years of age about ways to reduce or eliminate
allergens and motivating them to pursue these steps (building on the National Cooperative Inner-City Asthma
Study, see below). Interventions are tailored to eliminate tobacco smoke and specific allergens (Morgan et al.,
2004).
Interactive Multimedia Program for Asthma Control and Tracking (IMPACT): An interactive educational intervention
(electronic) for children and parents to use in a clinic setting. Each lesson is about 1 minute in length and covers
basic pathophysiology, environmental triggers, quick relief and control medications, and strategies to control and
manage asthma (Krishna et al., 2003).
National Cooperative Inner-City Asthma Study (NCICAS): A comprehensive community-based initiative designed to
identify symptom triggers, reduce asthma symptoms, and improve the quality of life for inner-city children aged
5 to 11 years. Its focus is on asthma education, tailored self-management techniques, and improving physician
interaction with patients. The Guide for Helping Children with Asthma is the primary intervention material
(R. Evans et al., 1999).
Open Airways for Schools (OAS): A widely used intervention for implementation in the school setting. It teaches
children 8 to 11 years of age about prevention of asthma episodes, symptom recognition, and appropriate selfmanagement (Clark et al., 1986; D. Evans et al., 1987; D. Evans, Clark, Levison, Levin, & Mellins, 2001).
Physician Asthma Care Education (PACE): An interactive seminar that focuses on treatment, communication, and
education/behavior of physicians and their impact on patients. It also provides information on reimbursement for
patient education in the clinic setting (R. Brown, Bratton, Cabana, Kaciroti, & Clark, 2004).
Wee Wheezers: An asthma education intervention, delivered in a clinic setting, for parents of children younger than
7 years old who have asthma. This intervention includes education on asthma management and communication
skills. It also addresses the psychosocial well-being of the family unit (Wilson et al., 1996).
Wee Wheezers at Home: An educational intervention, delivered in the home setting. The course, conducted by
registered nurses, is tailored to the developmental level of children younger than 7 years with regard to selfmanagement and covers basic concepts of asthma, cues, medication techniques, symptoms, and action plans
(J. V. Brown et al., 2002).
Yes We Can: A new model of clinic-based care developed for use in poor urban communities that integrates
patient education and community approaches. Using a team approach (doctor, nurse, care coordinator, and
community health worker), families and children receive education regarding asthma medications and
prevention. Home visits include guidance on how to address environmental triggers (Thyne, Rising, Legion, &
Love, 2006).
You Can Control Asthma: A nurse-administered pediatric asthma intervention for hospitalized children ages 4 to 12
years. The low-literacy education component is for families and children and focuses on how to prevent and manage
asthma episodes (Taggart, Zuckerman, Lucas, Acty-Lindsey, & Bellanti, 1987).
3. establish partnerships with entities in both the public and private sectors to reduce the burden of
asthma in children and their families;
4. integrate evidence-based childhood asthma program
models into communities and health care systems
for potential national replication;
5. create new and enhance existing linkages among
health care providers, schools, community-based
organizations, patients, parents, and other caregivers; and
6. improve health and related outcomes (e.g., asthma
symptoms, access to high-quality care, appropriate
use of the health care system), and improve quality
of life for children who have asthma.
In pursuit of its goals, MCAN challenged local programs to
• improve access to and quality of asthma health care
services for children,
• enhance knowledge of and promote positive behaviors toward asthma among affected individuals and
the general public,
• make communities and schools more asthma-friendly,
• promote asthma-safe home environments and
• reduce disparities in childhood asthma outcomes.
These specific objectives served as the drivers for the
activities and outcomes of the MCAN initiative; evaluation efforts also focused on these objectives (Viswanathan
et al., 2011).
MCAN Site Selection Criteria and Process
The MCAN initiative targeted the pediatric population (age <18 years). Consistent with the program goal of
reducing disparities in childhood asthma outcomes,
impoverished and medically underserved children and
their caregivers were of special concern. Prospective
applicants were encouraged to adopt and adapt interventions that best addressed the childhood asthma issues
and opportunities in their particular communities. MCAN
encouraged applicants to either select from the identified
evidence-based interventions (Table 1) or provide proof
of efficacy for supporting other interventions. Applicants
were also encouraged to describe any special strategies
they intended to use to address health and health care
disparities for children in the community.
MCAN strongly encouraged a comprehensive approach,
involvement of community stakeholders, and a broad
coalition or consortium support. Applicants were also
encouraged to address all of MCAN’s goals. MCAN
expected applicants to articulate specific and quantifiable
objectives and a plan for measurement of process and
outcomes. MCAN also expected applicants to demonstrate plans for sustainability of the core elements of
their programs at the end of grant funding. MCAN
selected sites based on creativity and significance of
project goals; feasibility of project plan and integration
of program components; collaborative relationships
and linkages; experience and qualifications of applicant, personnel, and organization; evaluation plan; and
sustainability.
MCAN Sites
MCAN funded five projects, in Chicago, Los Angeles,
New York City, Philadelphia, and San Juan (Puerto
Rico), from 2005 to 2009. MCAN chose sites that had
previous experience with a collaborative and comprehensive multisystem approach to asthma control, to
allow relatively quick development of programs and
processes. All five program sites are located in large
metropolitan areas with high rates of asthma prevalence, complex social issues, and various infrastructural barriers (Table 2). All communities had
both significant pockets of poverty and high asthma
morbidity. Four of the five sites had some prior experience with asthma programs, either in the local area or
within a subset of the local area, and all four intended
to use MCAN funds to build on prior relationships from
previously funded projects (Puerto Rico), to enhance
ongoing services (Los Angeles, New York City), or to
expand to new areas (Philadelphia). Chicago had minimal history of prior work in the focal area but substantial experience in a neighboring area and strong
representation of local community organizations. The
number of participants to whom the program sites
expected to offer enrollment to the core intervention
varied at the time of their proposal to MCAN in 2005,
as did the level of asthma morbidity addressed and the
types of interventions implemented.
Each site chose a unique portfolio of activities to
achieve MCAN goals. Central to the activities for all sites
was a focus on care coordination for children. As site
partnerships, staffing, and experience evolved over time,
so did their specific portfolios (Table 3). Implementation
of key elements as proposed was challenging. Sites
added and dropped parts of interventions, and they also
adapted interventions based on their self-evaluation of
performance, staffing skills, receptivity of the intended
audience, and needs and constraints of partners.
In keeping with their commitment to common overall
goals, sites infrequently dropped entire elements of their
15S
TABLE 2
Background Information for MCAN Sites
Key Factor
Chicago
Los Angeles
New York City
Philadelphia
Puerto Rico
Geographic scope
(by year)
Years 1-4:
Englewood
and West
Englewood
(Greater
Englewood)
Years 1-2:
Washington
Heights/Inwood/
West Harlem;
Years 3-4:
Expansion to
other parts of
Harlem
Year 1: West
Philadelphia; Year 2:
South Philadelphia;
Year 3: Northwest
Philadelphia; Year 4:
Lower Northeast
Philadelphia
Previous
experience of
key grantees in
the community
Minimal in
Englewood
and West
Englewood;
substantial in
neighboring
Grand
Boulevard
area since
1990
2002 (ages 0-17
years):
Englewood,
58.3; West
Englewood,
70.0
Englewood:
$18,955; West
Englewood:
$26,693
Englewood: 43.8
%; West
Englewood:
32.1%
Englewood:
98.8% Black;
West
Englewood:
97.8% Black
Years 1-4:
Eight
districts of
the Los
Angeles
Unified
School
District
(LAUSD)
Continuing
and
expanding
on LAUSD’s
Asthma
Project since
1999
Operating in
Northern
Manhattan
schools since
1999
Continuing and
expanding on the
work funded by
Alliesa in Northern
Philadelphia
beginning in 2000
Years 1-2: Luis
Lorrens
Torrez
housing
project; Years
3-4: Manuel
A. Perez
housing
project
Substantial;
both housing
projects were
involved in
Alliesa
beginning in
2000
2005 (ages 0-17
years):
Washington
Heights/Inwood,
43.0; West
Harlem, 91.0
Washington
Heights/Inwood:
$28,865; West
Harlem: $27,365
Washington
Heights/Inwood:
30%; West
Harlem: 32%
Washington
Heights/Inwood:
74.1% Hispanic,
8.4% Black,
13.6% White;
West Harlem:
43.2% Hispanic,
31.3% Black,
17.8% White,
5.1% Asian
2004 (ages 5-13
years): 58.9
Pediatric asthmarelated
hospitalization
rate per 10,000
children
Median incomec
Live below
poverty levelc
Racial/ethnic
distributiond
2001 (ages
0-17 years):b
53.1
$36,687
22%
72.8%
Hispanic,
11.6% Black,
9.0% White,
3.8% Asian
$30,746
2001 (ages 0-17
years): Luis
Lorrens
Torrez, 137.0;
Manuel
Perez, 99.0
$8,393
37%
48.2%
17.0% Hispanic,
70.3% Black,
13.3% White, 4.2%
Asian
98.9%
Hispanic,
8.0% Black,
80.5% White
NOTE: Unless otherwise noted, data are from sites’ 2005 proposals.
a. Allies Against Asthma, a Robert Wood Johnson Foundation program.
b. California Health Interview Survey, 2001.
c. 2000 U.S. Census. Data for Los Angeles and Philadelphia include the entire city; San Juan income and poverty level data are from the Puerto
Rico Planning Board, 2002.
d. 2000 U.S. Census data, with the exception of Los Angeles, which uses LAUSD 2004-2005 enrollment data (http://search.lausd.k12.ca.us/
cgi-bin/fccgi.exe?w3exec=PROFILE0).
TABLE 3
Evolution of Key Intervention Components of the MCAN Care Coordination Model
Key Intervention Component
Chicago
Provider (clinics, mobile van, and hospital) interventions
Train physicians

Disseminate asthma management materials to
NA
providers (toolkits or provider training materials)

Reach out to providers to improve referrals to
and from MCAN program
School-based interventions

Train teachers or school nurses
Educate students

Disseminate asthma management and indoor

air quality materials (asthma action plans,
asthma toolkits, Tools for Schools)
Reach out to schools to improve referrals to

and from MCAN program

Screen for asthma
Home-based interventions
Assess the environment

Disseminate asthma management materials

(educational and environmental materials)
Educate caregivers and/or provide referrals

Community-based interventions
Disseminate asthma management materials

(action plan)

Reach out to communities to improve
referrals to and from MCAN program
Screen for asthma

Educate caregivers/public

Promote linkage and integration of services in

the community

Promote policy change
Los Angeles
New York
City
Philadelphia
San Juan










NA



NA











NA



NA
NA


NA













NA

NA



NA
NA








NA
NA





NOTE: MCAN = Merck Childhood Asthma Network, Inc.;  = planned activity conducted as originally intended;  = one or more
activities modified from original intent; 
 = dropped after project initiation;  = in initial work plan but not implemented; NA = not
applicable—site did not intend to implement component.
interventions; often, when one intervention was not successful, they sought to replace that intervention with
another one with similar aims. Physician training was
the single key element most likely to be dropped: Sites
often found low receptivity to the intervention among
their intended audience. Home-based interventions that
were closely tied to care coordination were least likely to
be modified from their original intent; indeed, as the
programs evolved, all sites gravitated toward placing
care coordination at the center of their programs.
Discussion
>>
The MCAN approach required sites to be comprehensive (to support changes in health care systems,
families, organizations, institutions, community, and
public policy) and evidence based; to engage partners;
and to develop coalitions in pursuit of improved health
outcomes. In keeping with its focus on supporting
improvements in health outcomes rather than research
per se, the MCAN initiative offered latitude in how to
17S
achieve these goals. The results offer some lessons to
other funding initiatives with similar goals.
In response to the required MCAN goal of comprehensiveness, sites set out to accomplish an ambitious
array of interventions. The cost of comprehensiveness
was dispersed focus. Because sites were given some
latitude to implement intervention components to
accommodate contextual requirements of their individual communities, sites could reprioritize and sharpen
focus over time. As a result, over time all focused on
the core component of care coordination, with home
visits as needed (Findley et al., 2011). In addition, sites
strengthened tasks that supported their core activity of
care coordination.
The MCAN initiative required sites to use evidencebased interventions but did not narrowly restrict the
choice of interventions. As a result, sites selected varied types of interventions to reach the same goals. The
degree of variability inherent in this design resulted in
a real-world translational effort, with attendant successes and challenges. Chief among the successes was
the demonstrated improvement in outcomes (Mansfield
et al., 2011); chief among the challenges were fidelity
to the chosen evidence-based interventions (Lara et al.,
2011) as well as evaluation, particularly in establishing
casual relationships between specific intervention
components and outcomes (Viswanathan et al., 2011).
The MCAN initiative also focused on community
engagement and coalition support. This approach
allowed sites to strive for common goals while addressing the unique challenges of their own communities by
adopting or adapting effective interventions (Lara
et al., 2011). MCAN’s strong emphasis on community
partnerships resulted in continued strengthening of
some of these linkages; other partnerships evolved or
dissolved over time (Rojas Smith et al., 2011).
A key unifying theme to the results of the MCAN
initiative is the central role of adaptation in implementing evidence-based interventions in real-world settings.
The successes and challenges faced by MCAN sites highlight the recursive nature of implementation research.
The success of the MCAN initiative in improving health
outcomes despite different approaches to care coordination leads to the question: Do care management and/or
home-based interventions produce improvements in
health outcomes regardless of the specific components?
If so, what aspects of these interventions are most costeffective? Similarly, the difficulty that MCAN sites faced
in implementing physician training begs the question,
how can physician training interventions be modified to
improve their acceptability? The pursuit of these answers
will help to advance the adaptation of interventions that
work in real-world settings.
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19S

The Merck Childhood Asthma Network, Inc. (MCAN)

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