State of New York: Statewide Approach to Asthma Education through Regional Coalitions

New York state's Open Airways For Schools' experience has become the cornerstone of a comprehensive asthma education program, based in regional childhood asthma coalitions focused on reducing the burden of childhood asthma in New York. While state-funded coalition work involves more than school education, the entire initiative was assisted by the American Lung Association's Open Airways For Schools efforts, which remain a foundation of asthma education throughout the state.

The development of this large-scale effort and its ongoing work are the result of a confluence of school nurse momentum, insight of the state departments of health and education, the American Lung Association's commitment, and support of the Centers for Disease Control and Prevention.

Note: Some points of activity of the American Lung Association of New York State, which managed development of the regional asthma coalitions with the state of New York, intersected with Open Airways For Schools initiatives in New York City, managed by the American Lung Association of the City of New York (also profiled).

Site Background

The 704 hundred four school systems throughout New York state encompass 4,200 public elementary and secondary schools and have a student population of approximately 2.8 million children1; approximately 2800 of these schools are elementary and middle schools.2 3  Additionally, 480,000 students attend 2,175 private elementary and secondary schools. An estimated 383,361 children under age 18 in New York had asthma in 2002.4 School nurse ratios vary by district, as school health standards differ across the state, and school nurse roles can vary within the same district.5

Open Airways For Schools is currently funded and implemented by eight of nine state-funded Regional Childhood Asthma Coalitions created to build local capacity to reduce the burden of childhood asthma in New York. Coalitions' long-term outcomes goals are to decrease school absenteeism, hospitalizations, and emergency room visits. School-based asthma initiatives are intended to close the communication and asthma management gap among schools, health care providers and parents/children with asthma. When those gaps are closed, children with asthma would be living with a consistent asthma management support system. The six coalitions outside New York City that have Open Airways For Schools as part of their requirement are staffed by employees of the American Lung Association funded by the New York State Department of health grants. American Lung Association of New York State staff managed development of most of the regional coalitions.

Between 2000, when the first childhood asthma coalitions began working, and school year 2003-2004, 5960 children with asthma in targeted elementary schools have completed Open Airways For Schools under the coalition program (based on the American Lung Association national reporting). This outreach, however, represents only a top-line implementation, with the American Lung Association of New York State's goal remaining to implement Open Airways For Schools in every elementary school in the state; the in-depth reach into many more schools is the ongoing work of the regional asthma coalitions in conjunction with the American Lung Association.

Program Implementation & Evolution

When Open Airways For Schools first became available, the American Lung Association of New York State's initial strategy was to recruit schools by presenting the program to school nurses directly. As the schools' frontline health professionals, they inherently understood Open Airways as a tool to address the education needs of their students with asthma. Due to school nurses' workload, however, it became apparent that they would have difficulty incorporating the program into their schools, particularly since it had not yet been evaluated under the state's umbrella. After discussions with nurses in the field and previewing the program at their training conferences, the American Lung Association in 1996 brought Open Airways For Schools up the chain of authorization to the Department of Education's Health and Pupil Services Unit, where the Association had existing relationships.                                                                                                                         

The overall concerns of nurses, coupled with the Health and Pupil Services Unit's management, resulted in asthma being acknowledged as an imminent liability in the schools. To move forward with the American Lung Association and Open Airways For Schools, the Department of Education required a pilot program through which the state could collect and analyze data on the program's effectiveness; the pilot was conducted by the Department of Education with the American Lung Association of New York State and evaluated by the Kresge Center for Nursing Research (State University of New York) during school year 1997-98.

The state Department of Health was simultaneously becoming more concerned about asthma as a public health issue, which was being highlighted by the Centers for Disease Control. With CDC's attention focused, in part, on the need for state-coordinated asthma initiatives, the Department of Health became more cognizant of its very real and increasing asthma problem and turned to the American Lung Association to help construct a community-based plan. Pending results of the Kresge pilot, the governor's office and the Department of Health's community health education staff were ready to seek state funding to address New York's asthma problem.

The Kresge evaluation of 369 children during school year 1997-98 showed that children who completed Open Airways For Schools experienced fewer school health office visits, missed school days, doctor's visits, emergency room visits, and hospital stays; and parents of children in the pilot experienced fewer missed work days. In general, children who qualified for the school lunch program experienced more dramatically favorable results.

The results of the Kresge study, which confirmed the validity and efficacy of Open Airways For Schools, became the catalyst for the state's endorsement of the program, which is continuing to propel statewide implementation of Open Airways For Schools. New York's community-based coalition approach was ready to take off.

While the Department of Education did not formally mandate use of Open Airways For Schools, the program is implemented with the ongoing support of the department's School Health Services. Most coalitions include a local representative of School Health Services.

Coalition Work

The American Lung Association of New York State illustrates asthma management as an "unconnected triangle" in which parents and their children, health providers and schools are all part of a child's asthma management but are not necessarily working together efficiently. With a graphic illustration that leaves a triangle's three angles literally unconnected, the concept underlines the need for clear communication and partnership among providers, schools, and the family to efficiently manage a child's asthma. The concept has come to frame New York's Regional Childhood Asthma Coalitions' work. Specific coalition activities include: asthma education and training for schools through Open Airways For Schools; asthma education for families, communities, schools and daycare; asthma education for health care professionals; asthma care coordination for high-risk children; and  data systems development.

Coalition members vary by region but typically may include HMOs, county or municipal health departments, medical/hospital systems, visiting nurse agencies, school districts, community foundations, pharmacologic societies (schools of pharmacy), and college nursing and respiratory therapy programs.

Regional coalitions recruit and train Open Airways For Schools instructors and handle all logistics of program implementation. Coalition coordinators, who are trained by American Lung Association of New York State staff, train volunteer instructors. One particularly solid source of volunteer instructors has been nursing students, who are required to participate in community service as part of their curriculum.

School nurses are the program contact within each school and typically are responsible for coordinating sessions within the school, serving as the contact person for parents, and overseeing the volunteer instructors. Nurses also distribute and collect pre- and post-test questionnaires. Community-based partnerships provide opportunities for funding, volunteer instructors, and entrée to key school contacts.

The American Lung Association of New York State continues to play a critical role in moving the Regional Coalition program forward, working closely with the Department of Health and Department of Education. Staff will be overseeing the next evaluation process within the state and continues to emphasize the need for coalitions to follow the exact program to ensure program standards. Staff also collects all pre- and post-tests for evaluation.

Funding 

Nine regional coalitions are funded through Department of Health grants as well as individual coalitions' additional grants and sponsorships. The Department of Health funded $1.4 million to coalitions in its first grant cycle and $1.6 million in the second grant cycle. American Lung Association of New York State program staff are in continuous communication with key Department of Health and Department of Education staff, (via School Health Services), to ensure program continuity and to support efforts to secure ongoing state funding. This latter conduit and that of the School Nurses state association will likely be revisited in the near future. Local coalition contact with School Nurses in the field is ongoing. The American Lung Association of New York State's Chief Mission Officer has assumed contact with the Coalition Coordinators (outside of NYC), and will assume contact with state government staff in July 2005.

Challenges

As the regional coalition program evolves and expands, several challenges to Open Airways For Schools have arisen. The major challenge is to continue to position Open Airways For Schools as the base of a pyramid of school-based asthma education and the mandated school program for Regional Childhood Asthma Coalitions. Some new school-based coalition activities have the potential of being misinterpreted within that pyramid, where Open Airways must remain the base. For example, a blossoming initiative places nebulizers in school nurses' offices for treatment of asthma episodes. While this activity can become an integral piece of asthma case management in the schools, it cannot be misinterpreted as a substitute for or a next-step beyond Open Airways For Schools. Both activities are integral pieces of asthma management and should be working cooperatively rather than competitively within schools.

Additional challenges to systemic implementation of Open Airways For Schools in New York state include:

  • effectively managing Open Airways For Schools among new coalition activities, to ensure program standards;
  • funding to support administration of systems throughout regional coalitions;
  • keeping coalition membership a manageable size to focus partners' agenda

Impact

Nearly 6,000 children have participated in Open Airways For Schools under New York's coalition program (2000-2004 data). They were taught by 1,134 instructors trained throughout the state by the American Lung Association. The program's impact, however, reaches far deeper than just these numbers.

Open Airways For Schools, vis a vis the Regional Childhood Asthma Coalitions has raised the state Department of Health's visibility and impact on a national level. State staff receives CDC referrals from other states building their asthma programs and made several presentations at the last CDC asthma conference. This not only reflects well on the state and state staff; it also provides incentive for the state Department of Health to continue bolstering the program, funding it appropriately, and providing leadership among states.

For the American Lung Association of New York State, work with the state has allowed Open Airways For Schools to make an impact on asthma, although the association has extensive plans to expand program reach through the coalitions to encompass asthma case management. Having the program managed by state-funded coalition coordinators has been a financial boon to the American Lung Association; in some cases, Open Airways For Schools would not be implemented without the coalition structure.

Offering Open Airways For Schools as a validated, nationally-driven program has heightened the asthma work of the American Lung Association of New York State and created an open door to partnerships. The specific coalition experience was transferred to American Lung Association of New York State youth tobacco initiatives. The association patterned a youth tobacco grant loosely after the asthma coalition model and secured funding for a three-year cycle to place tobacco cessation (including the American Lung Association's N-O-T program) in a limited number of schools in four regions.

The program success also has created excellent visibility within communities and to funders. It also has begun to create some crossover into other American Lung Association activities such as Asthma Walk.

Three components have been critical to the American Lung Association of New York State's Open Airways For Schools experience: leveraging existing relationships to garner large-scale support for the program; securing state endorsement through program evaluation; and understanding and maximizing existing state structure that impacts asthma and potentially Open Airways For Schools. All work is based on both the validated program standards and schools' understanding of the critical nature of asthma; indeed, schools need to erase the liability of having an asthma attack—and potential fatality—from happening in a school.

New York's state structure has been critical to the program's success. Both the Department of Health and Department of Education are invested in confronting asthma and making positive impact. Without that commitment, Lung Association staff otherwise would need to magnify liability issues in a balanced manner to garner support. Advocacy efforts can support education-focused work and help identify opinion-leaders with personal ties to asthma. Through work leading up to the state's passage of an inhaler self-carry law, for example, staff learned of legislators who have children with asthma. The enactment of that law, furthermore, helps schools reduce risk.

The statewide partnership has resulted in a cohesive effort that empowers the students and their families to mange their asthma in concert with the schools and their healthcare providers.



1. Office of Elementary, Middle, Secondary and Continuing Education Strategic Plan. December 2000.

2. New York State Education Department. The State of Learning: Report to the Governor and Legislature—Statewide Profile of the Educational System, 1995. Trend Projection – 2003.

3. New York State Education Department. Directory of Public Schools and Administrators in New York State, 1999.

4. Estimated Prevalence and Incidence of Lung Disease by Lung Association Territory 2004. American Lung Association. September 2004.

5. Making the Difference: School Nurses Impact Student Achievement. New York Statewide School Health Services Center. Accessed February 2, 2005 at http://www.schoolhealthservices.org/news.cfm?story=9