The Vendor is required to provide asthma case management services in the south county as part of the newly formed county asthma program.
- Department aims to reduce asthma-related health disparities by contracting with approximately two providers to deliver culturally competent, family-centered case management services that strengthen care coordination and promote asthma self-management among residents in the south county.
- Services should be delivered using a comprehensive case management model, designed to provide personalized, coordinated care to enrolled pediatric asthma patients and their families.
- Responsible for delivering case management services that address the unique needs of each patient and their family.
- Case management services should be provided in a way that emphasizes a holistic approach, focusing on the following key parameters: assessment, care coordination, education and support, monitoring and follow-up and advocacy.
- By implementing a comprehensive case management model, the contractor will aim to improve health outcomes, enhance the quality of life for pediatric asthma patients, and empower families to manage asthma effectively.
- Evidence suggests that the common factor for successful childhood asthma case management entails case managers spending time contacting and patiently and persistently working with the family, thus building a trusting relationship.
- Case management programs teach children and families basic facts about asthma, the role of medications, the correct way of using asthma medications, how to respond when asthma symptoms get worse, and how to reduce exposure to asthma triggers, in addition to coordinating care and resources to help the client reach their goals.
- Although case management time is an expense for a health care payer, provider, and the child and family, the positive outcomes achieved can demonstrate the benefit of these interventions to all parties involved.
- Comprehensive Case Assessment
• Conduct an initial assessment that includes:
o Asthma severity and control level
o Medication usage and adherence
o Environmental triggers(e.g., pests, mold, tobacco smoke)
o Social determinants of health (housing, food access, transportation, etc.)
• Develop an individualized care plan in collaboration with the family and healthcare provider.
- Identification and Enrollment
• Collaborate with hospitals, clinics, schools, and community partners to identify and enroll county children (ages 0–17) with moderate to severe persistent asthma or frequent ED visits.
• Obtain appropriate consent and conduct initial outreach to families referred for case management.
- Ongoing Case Management and Follow-Up
• Provide continuous support for up to six months per family, including:
o Ensuring prescriptions for long-term control medications are filled and used correctly
o Confirming primary care and specialist appointments are scheduled and attended
o Conducting regular follow-up calls or visits (minimum monthly contact)
o Addressing barriers to care, including transportation, insurance, or pharmacy issues
- Ensure the child received prescribed medications and has a follow-up appointment with a primary care provider.
- Maintain case files and electronic records documenting all services and contacts.
- Contract Period/Term: 1 year
- Provider Conference Date: January 7, 2026
