Secure Funding

Design Program

Hire and Train Staff

Enroll Clients

Assess Client Needs

Identify Triggers

Plan For Remediation

Track Outcomes

Cultivate Partnerships


Using the Roadmap

On this page, you'll see nine primary waypoints to consider as you embark on your journey to provide home-based asthma services. We've arranged them into one possible route as an example for those who want a premade path.

However, you are able to rearrange these waypoints to create a route that best fits where you are and where you still need to go. Simply click one of the colored tabs on the left side of a segment and then drag and drop it into the order you prefer; you can move as many or as few segments as you like. You'll see the order move both in the pins along your route at the top of the page as well as in the more detailed list below.

To expand or collapse each section and view the details for each waypoint, click the "MORE" or "LESS" arrows along the right side. You're also able to email, print, or share your final roadmap using the three buttons toward the bottom of the page.

Feel free to contact us with technical questions about using this tool at any time or reach out to talk about how we can support you in developing your roadmap for embarking on your journey!

  • Identify or secure funding to support program goals of improving asthma outcomes and reducing disparities.


    Such funding may include Medicaid managed care plans, other health plans, grants, hospital community benefits, donations, et cetera.

    If you don’t already have a funding source, learn about general funding sources and explore opportunities in your community/state.

    Consider the value of making the business case to potential funders.

    Having trouble understanding what resources are available in your community? Reach out—we can help!

  • Determine the core components of your program design.


    Establish eligibility criteria. Consider focusing on people at greater risk or with more poorly controlled asthma.

    Determine the type(s) of asthma home visitor(s) that will be most effective at helping to meet the program’s goals and align your staffing structure accordingly.

    Establish the baseline level and intensity of the services available in your program, including asthma self-management education, in-home environmental asthma trigger assessments, and environmental asthma trigger remediation supplies and services. You’ll also need to determine over how many visits the services will be provided.

    Determine whether a virtual or hybrid approach would add value to your program.

  • Hire and train your asthma home visitors.


    Determine if there are existing training requirements and/or training programs in your community or state. Ensure that the training aligns with national asthma clinical guidelines and includes robust guidance on identifying and addressing environmental asthma triggers.

    Connect your staff with the training program, along with hands-on training opportunities and additional training on cultural humility, motivational interviewing, or other relevant topics.

    Consider ongoing professional development opportunities based on emerging needs and interests.

  • Create a process to identify and enroll clients.


    Plan and conduct outreach and recruitment.

    Build relationships for referrals with health plans, clinicians, schools, community-based organizations, and others.

    Establish enrollment processes and tools (such as intake forms and consent forms).

    Encourage staff to use enrollment to build rapport with clients.

  • Build a system to assess client needs and provide asthma self-management education.


    Work with asthma home visitors to develop key educational messages and identify educational tools they can use to support or augment the education they provide.

    Ensure that the visitors providing in-home asthma services practice cultural humility and focus on building trust and rapport with clients.

    Provide ongoing support for the asthma home visitors in addressing challenges and engaging in peer learning to discuss strategies and identify best practices. Looking for educational tools to use or adapt for your program? Visit the Asthma Community Network’s Resource Bank.

  • Establish your approach to asthma environmental trigger assessments.


    Select the environmental asthma trigger assessment tools that your program will use.

    Ensure that your asthma home visitors receive training and support in conducting the assessment and determining when additional or more advanced assessments may be necessary (for example, an extensive pest problem or the presence of lead paint will likely require additional support and expertise).

  • Develop a plan to conduct remediation activities.


    Provide education around reducing exposure to the triggers identified.

    For renters, ensure that clients understand their rights and work with them to engage landlords and/or connect them with legal aid, if appropriate.

    For property owners, provide references to home repair programs and resources.

    Select the remediation products and services that your program will provide or contract with others to provide.

  • Track activities and outcomes.


    Determine your evaluation questions and measures based on organizational, partner, funder, and client priorities. Consider decreased healthcare utilization, improved asthma control, reduction of triggers, improved knowledge, confidence, self-management behaviors, program costs and benefits, and quality of life improvements, among other topics. Don’t forget nontraditional outcomes like articulating the value of the relationship between clients and home visitors.

    Develop tools for collecting and analyzing data.

    Use the data to monitor and inform program improvements and continue to make the business case.

  • Throughout this process, cultivate partnerships with organizations and community.


    Partnerships with providers and health plans are important for ensuring that asthma home visiting is integrated into a broader approach to asthma management.

    Partnerships with organizations that provide other housing services, social services, and legal services can help asthma home visiting programs support clients more effectively.

    Engage community members directly to build organizational trust and rapport and deepen your understanding of community needs and priorities.

    Need support in developing your asthma home visiting program? Looking for specific tools or resources? Reach out—we can help!!

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What’s Next?

Take a moment to…

  • Register on NCHH’s e-learning course directory and access all 10 modules in the Building Systems to Sustain Home-Based Asthma Services course, all the resources linked throughout the roadmap, and many other key resources and technical assistance tools to support your work.
  • Visit our new resource, Unlocking the Power of Home-Based Asthma Services: Model Health Benefit Packages, a tool for managed care plans and allies describing the scope, staffing, and services associated with home-based asthma services that identify and address environmental asthma triggers in the home environment. This tool includes tiers of services (from a basic set to more premium sets of services) to provide several options for payers at various levels of readiness to provide home-based asthma services and includes recommendations to support action from a range of critical stakeholders.
  • Contact us to learn more about free available technical assistance and/or the project overall.