Moving Beyond the Hospital Walls: The Value of Meaningful Clinical-Community Partnerships

While many providers, hospital administrators and community agencies know social factors such as food insecurity, parental smoking habits, and housing are critical to children’s health and well-being, there are multi-layered barriers to screening for these caregiver- and family-focused needs in pediatrics. In our first installment of this series, we addressed the feasibility of screening during children’s medical visits. Our second blog post discussed provider reimbursement for caregiver-directed services. This third and final post addresses the formation of meaningful clinical-community partnerships. 



As a clinician, it can be difficult to acknowledge that a 15-20 minute interaction with my patients is not enough time to teach families about how to care for asthma – the most common chronic condition among children. Imagine it, 15-20 minutes and then I don’t see my patients and their caregivers again for up to a year, leaving them at-risk for repeat hospitalizations if their asthma remains uncontrolled. Twenty years ago, I couldn’t help but wonder what more we could do.

Thinking back to my own childhood in a small, poor, southern community, I realized that we were self-sufficient because everyone in the community played a part. The different pieces of the community that came together to support me allowed me to be where I am today. I believed that there must be strength in the Philadelphia community that we can utilize together with our own health care efforts to make a difference! Thus, we started the Community Asthma Prevention Program (CAPP) at Children’s Hospital of Philadelphia, which has depended on community partners from its inception to facilitate connections not only with our patients, but with their parents too in order to impact the social risk factors that affect asthma control.

Recognizing the problem is just the beginning

As we formed CAPP, we reached out to Philadelphia residents, community agencies, schools, housing agencies and managed care organizations, all of which were not yet perceived as experts in their communities. It was important to us that instead of coming in and telling them what we thought they needed, we utilized their expertise to find the best ways of helping children manage their asthma.

In doing one-on-one interviews with these community members, we heard comments like “I didn’t know that asthma could kill you,” and “I didn’t know that black children suffered more from asthma than others.” This gave me the opportunity to share some facts, but also to ask their advice on how we make sure that people know the best ways to control asthma so it doesn’t become life-threatening.

We began community classes to address these issues (which we’ve now done at over 80 sites), but we realized that we also needed community residents to provide more in-depth education for parents of children who are at high risk for hospitalizations and emergency visits. Thus, we started our community health worker program, which employs community members to provide asthma education and trigger remediation in patients’ homes as well as care coordination – key intergenerational services.

Forming strong partnerships in the community

Over the years, each of these community groups has proven vital to our success. Here are some of the things I’ve learned from working with these partners:

  • Community Residents: CAPP community health workers, or community residents trained to implement at-home interventions, have conducted more than 20,000 home visits over the past 20 years. Home visiting services that identify and address parents’ and caregivers’ physical, social and mental health needs have been shown to also improve children’s health, development and well-being. Our program’s community health workers, sometimes referred to as “the asthma ladies,” utilized highly valued expertise in not only asthma prevention, but their community knowledge to connect with parents and children to reduce emergency and hospital visits through intergenerational services. The asthma ladies also led community classes, during which we discovered parents were eager to learn through facilitated peer interaction, particularly in familiar community spaces.
  • Community Agencies: Many community agencies already have an “in” with the community because they provide needed resources for residents. Recognizing this, we partnered with them to provide sites for hosting community classes. However, to ensure the best experiences for the families, we create an agreement before hosting a class that describes CAPP’s and the community site's responsibilities. Other vital community agencies include housing partners that are often overwhelmed with the far-reaching needs of the community. We work with them to identify best practices for making the environment child-friendly, which has been the best way to affect the physical spaces in which our patients interact.
  • Schools: Schools present great opportunities to partner, as they are trusted spaces where children and families are already present. Identifying a champion within the school to help understand the culture and context of the area is an essential step prior to beginning any intervention.
  • Managed Care Organizations (MCO): Partnering with MCOs early allowed us to learn about their needs and interests. By learning to speak their language and proving our value, as a research team that provides rigorous evaluation, to their bottom line we’ve been able to maintain consistent contracts for CAPP home visits for children with asthma. This innovative contractual relationship has been a huge success for our program and a demonstration of their commitment to improving health outcomes of kids.

Community partnerships take time, but are essential for long-term progress

CAPP is considered a model for other community programs across the country because of its 20-year success working closely with parents, community agencies, public health professionals and school educators. As a result, we formed a CAPP Collaborative in 2008 with approximately 20 agencies who continue to be a part of any planning we do when applying for funding for our evidence-based intervention. CAPP also hosts an annual Fighting Asthma Disparities Summit during which national leaders share the state of asthma disparities and current interventions to improve asthma. We also learn about local initiatives that may reduce asthma disparities in Philadelphia.

While many of our referrals are word of mouth from previous families, more initiatives are on the horizon with CAPP through new community partnerships. The Philadelphia Health Department is helping scale CAPP across the city. And through the BUILD Health Challenge award, we are partnering with housing agencies to do major repairs in the homes of children with asthma - a long-standing dream of mine.

I am very thankful and grateful to our many partnerships over the past 20 years because without them, CAPP could not be what it is today. It is through these partnerships that we’re able to provide vital services to children, and intergenerational services to parents, in order to impact the social risks that can hinder asthma control.