Community Coalition Connects Medical Practices to Community Resources, Leading to Improved Asthma and Diabetes Outcomes in At-Risk Populations

Service Delivery Innovation Profile

Community Coalition Connects Medical Practices to Community Resources, Leading to Improved Asthma and Diabetes Outcomes in At-Risk Populations



King County Steps to Health, a federally funded coalition that ended in 2008, sponsored integrated initiatives that involved different organizations, including health organizations and community-based entities. The goal of these programs was to prevent the onset of diabetes, asthma, and obesity in at-risk populations and to improve the management of these conditions in those who have them. Between 2003 and 2008, the coalition has funded more than 20 initiatives. The program led to reductions in unhealthy behaviors and improvements in asthma and diabetes outcomes, including fewer hospitalizations and emergency department visits.

Evidence Rating

Moderate: The evidence consists primarily of before-and-after comparisons of key outcomes measures, including health-related behaviors, asthma symptoms, blood glucose levels, hospitalizations, and ED visits.

Developing Organizations

Steps to Health King County

Seattle, WA

King County Steps to Health, coordinated by Public Health–Seattle & King County, was a consortium of more than 75 members, including community-based organizations, health care providers, hospitals, health plans, clinics, universities, faith-based groups, government agencies, and school districts.

Date First Implemented



Problem Addressed

Asthma, diabetes, and obesity are increasingly common chronic conditions that have a significant, negative impact on quality of life and result in many preventable hospitalizations and deaths. These conditions are particularly prevalent in low-income, minority populations and are largely the result of poor health behaviors. Deficiencies in the existing medical and community infrastructure lead to highly fragmented care and the failure to receive appropriate outreach and referrals for at-risk individuals.

  • High prevalence of chronic disease in at-risk populations: Diabetes, asthma, and obesity are common problems, especially among low-income, minority populations. For example, in 2005, 22.8 million people had been diagnosed with asthma at some point in their life, with rates particularly high among Puerto Ricans, non-Hispanic Blacks, and American Indians.1 Approximately 8.3 percent of the U.S. population has diabetes with rates high among Hispanics (with 11.8 percent having diabetes) and non-Hispanic Blacks (12.6 percent).2 More than one-third of U.S. adults were obese in 2005 to 2006; obesity rates are higher among African Americans and Hispanics than among Whites.3 Over the last 15 years, the prevalence of adult obesity more than doubled, while the number of overweight adults increased by 20 percent in King County; currently, almost 60 percent of King County residents who live in the project area for the coalition are overweight, and more than 15 percent are obese.4
  • Leading to frequent hospitalizations and higher mortality: In 2001, 181.8 out of every 100,000 King County residents who live in the coalition's project area were hospitalized for asthma, including 335 out of every 100,000 children, a rate 2.5 times higher than in the rest of the county. During that same year, 140.2 out of every 100,000 King County residents who live in the coalition's project area were hospitalized for diabetes, twice the rate of the rest of the county; furthermore, the mortality rate for African Americans in King County who have diabetes is higher than for African Americans in any of the 10 largest U.S. counties.4
  • Poor health behaviors as a contributing factor: Physical inactivity, poor nutrition, and/or smoking contribute to a number of chronic conditions, including asthma, diabetes, and obesity. Surveys of King County adults indicate that 82 percent do not engage in regular and sustained physical activity; 75 percent do not eat the recommended five servings of fruits and vegetables a day; and 29 percent smoke (compared with 19 percent in the rest of the country).4
  • Deficiencies in medical and community organizations as a contributing factor: Deficiencies in chronic care in the clinic setting include rushed practitioners who do not always follow established care guidelines, lack of care coordination, lack of active followup, and inadequate training of patients to self-manage their condition.5 Deficiencies in the community setting include a lack of resources, coordination and integration of services, and policies that support health.4

Patient Population

The population of the target area for the Steps to Health program includes many minorities, including African Americans (representing 14.4 percent of the target population), Hispanic/Latinos (8.9 percent), and Vietnamese (3.9 percent). Approximately 30.4 percent of residents live below 200 percent of the Federal poverty level.

Description of the Innovative Activity

King County Steps to Health sponsored initiatives involving different organizations, including health organizations (e.g., hospitals, clinics, insurers, public health departments) and community-based entities (e.g., foundations, school systems, universities, city and county parks, faith-based groups, and the media). Coalition-sponsored programs encouraged organizations to work together to identify common messages, leverage resources, and develop programs and activities at the individual, family, clinical, school, and community levels. The coalition has sponsored more than 20 initiatives; several initiatives that link the health care sector with community organizations are described below:

  • Strong Kids: Strong Kids, a collaboration between the YMCA, Seattle Children's Hospital, and King County Steps to Health, incorporated strategies to promote overall health and well-being for overweight/obese children (ages 8 to 14 years) and families struggling to maintain a healthy lifestyle. Pediatricians referred children and their parents to the program.
  • Community health worker program: Participating hospitals and clinics referred patients with asthma or diabetes to community health workers, who came from the local community and have experience in managing these conditions. Most people who were referred have a low socioeconomic status. Community health workers contacted clients to set up an initial inperson meeting, and then made periodic home visits to encourage self-management and provided assessment, education, and action planning. Community health workers also promoted access to care by encouraging participants to attend their physician appointments and by referring clients to community resources. Community health workers updated referring physicians via written reports. Steps supported a registered nurse who had responsibility for overseeing the community health workers, both from a clinical and a management standpoint. The practicing general internists who provided oversight to the Steps program also gave additional clinical support to the community health workers in the form of periodic case conferences. The registered nurse checked in with the community health workers weekly (in person), and as needed at other times; she was always available by cell phone. Office space for the community health workers was provided by the department of public health.
  • Emergency department (ED) case management in chronic disease: ED-based registered nurse case managers at Harborview Medical Center managed patients according to detailed, internally developed protocols that included both medical and behavioral components. Case managers linked patients to a primary care home and to community resources, including the asthma and diabetes community health workers.
  • Aerobic swim program: This program, created jointly by a health clinic and a community center, referred at-risk individuals (particularly overweight women of color) to a special swim aerobics program held at a local community center. The clinic, which obtained a small grant from a local foundation to cover the costs of participation for low-income residents, reimbursed the community center on a monthly basis.

Context of the Innovation

King County Steps to Health was a federally funded consortium of community partners and public health officials in Seattle and King County, WA. Steps to Health interventions focused on the southern part of Seattle and adjacent communities in south King County, an area with a population of more than 300,000. The program began in response to the aforementioned statistics documenting the high prevalence of asthma, diabetes, and overweight/obesity in the area, especially in low-income, at-risk populations. As a result of these needs, Public Health–Seattle & King County (the public health department in the area) sought and was awarded a grant in 2003 from the Steps to a Healthier U.S. Cooperative Agreement Program (Steps Program), a national, multilevel program coordinated by the U.S. Department of Health and Human Services and the Centers for Disease Control and Prevention (CDC).


Pre- and post-implementation surveys and analyses of individual initiatives show that the program has led to reductions in unhealthy behaviors and improvements in asthma and diabetes outcomes, including fewer hospitalizations and ED visits. Macro-level evaluations of the entire coalition have not been completed; selected results from individual programs that have been evaluated include the following:

  • More physical activity: Among the 41 parent-child dyads who enrolled in the Strong Kids program (out of 94 referrals), pre- and post-implementation surveys show an 11 percent decline in the number of families with more than 3 hours of screen (television and/or computer) time per day and a 35 percent increase in the number of days where parent and child engaged in vigorous exercise.
  • Better outcomes for asthma patients: Patient surveys done at program initiation and exit reveal that asthma patients seen by community health workers reported symptom-free days and nights increased from 8.5 to 12.2 percent; the corresponding increase in symptom-free nights only was from 9.8 to 12.5 percent. The percentage of patients with an asthma-related hospitalization over the previous 12 months decreased from 12 to 5 percent, while corresponding figures for asthma-related ED visits fell from 46 to 21 percent.
  • Better outcomes for diabetes patients: More than 250 individuals have been served by the ED case management in chronic disease program to date. Preliminary results for the first 90 patients with diabetes indicate that nearly one-half were connected with a primary care home and, on average, reduced their hemoglobin A1c (blood glucose) levels by 1 percentage point as compared with baseline levels. ED use also declined among patient.

Evidence Rating

Moderate: The evidence consists primarily of before-and-after comparisons of key outcomes measures, including health-related behaviors, asthma symptoms, blood glucose levels, hospitalizations, and ED visits.

Planning and Development Process

Key steps in the planning and development process included the following:

  • Coalition created: Public health department representatives contacted colleagues in various sectors (schools, universities, health care organizations, and community-based organizations focused on nutrition and/or physical activity) and asked them to “spread the word” about the project to solicit participants. Open meetings were organized for interested parties, who formed the coalition.
  • Governance structure designed: Through a consensus process, the coalition created a 15-person leadership team that met on a monthly basis to review projects, approve funding, and review operations. A smaller executive committee helped with strategic planning and informed the agenda of the leadership team. The leadership team drafted bylaws that were approved by the coalition.
  • Project criteria developed: The team outlined an explicit set of criteria/principles (e.g., implementation of evidence-based programming) to govern project approval.
  • Sector-specific projects proposed: The coalition membership worked together by sector to develop project proposals. Each sector had multiple meetings to develop a set of recommended interventions.
  • Proposals evaluated: The leadership team evaluated proposals and created a funding priority list; it also located experts to help guide projects if needed.
  • Contracts monitored: A core staff supported by Steps to Health was housed in the public health department, provided administrative oversight of projects and grant funds, contract management, and technical assistance.

Resources Used and Skills Needed

  • Costs: The program cost roughly $9 million over a 5-year period, with funds used to support a core team of Steps to Health staff at the public health department and individual initiatives within the community.

Funding Sources

The program was funded by a $9 million, 5-year grant from the CDC. The funding ended in 2008.

Tools and Resources

Information about the CDC Steps Communities Program is available at

Getting Started with This Innovation

  • Create a formal coalition: The coalition provides a forum for convening different sectors and professionals to talk about common goals and strategies.
  • Develop an explicit, well-articulated statement about goals: This provides a framework for future initiatives and informs the selection of individual projects to fund.
  • Ensure senior leadership support: In large organizations such as medical centers and government agencies, senior leadership support is critical to the success of the program.
  • Cultivate champions: Champions should include both physicians and “bridge” professionals who serve as catalysts and community organizers, bringing entities together to develop initiatives.
  • Link medical and community organizations through appropriate operational steps: For example, with any initiative that links medical and community organizations, clinics should be made aware of available community resources. In addition, a formal referral process and standards for communication about referred patients should be designed to ensure a steady flow of referrals and overall clinician support.
  • Leverage assets and shared resources: Determine the availability of and access to ready-to-use tools and resources, including patient registries, educational materials and courses, guidelines, community Web sites, and patient support phone lines. These resources can be leveraged and adapted to quickly initiate program services. For example, Harborview Medical Center invited community representatives to participate in its chronic illness courses geared toward allied health professionals.

Sustaining This Innovation

  • Require grantees to track and report outcomes periodically: Ongoing tracking and reporting to the coalition will ensure that funded programs are producing results. However, smaller organizations that do not have expertise in data collection and measurement may need to rely on external technical assistance to track outcomes rigorously.
  • Share control: Although community-led efforts can be messy, system change is most sustainable if driven by the community.
  • Ensure ongoing funding and provision of in-kind resources: Initiatives cannot be sustained without funding or other resources. However, funding need not be extensive at the local level. With a modest amount of resources, most communities can leverage existing creativity and energy to produce positive results.

Contact the Innovator

Note: Innovator contact information is no longer being updated and may not be current.

James Krieger, MD, MPH
Chief, Chronic Disease and Injury Prevention Section
Public Health - Seattle and King County
Chinook Building, Suite 900
401 5th Avenue
Seattle, WA 98104
(206) 263-8227

Daniel Lessler, MD, MHA
Co-Director, King County Steps to Health
Associate Medical Director
Harborview Medical Center
325 Ninth Avenue; Box 359704
Seattle, WA 98104
(206) 744-2477

Innovator Disclosures

Drs. Krieger and Lessler have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.

References/Related Articles

The King County Steps to Health Web site is available at   A PDF of the King County Steps to Health Summary Evaluation Report, March 2009 is also available for download.


  1. Akinbami L. National Center for Health Statistics. Asthma prevalence, health care use and mortality: United States, 2003-05. Available at:

  2. American Diabetes Association. Diabetes statistics. Available at:

  3. Centers for Disease Control and Prevention. Obesity among adults in the United States—no statistically significant change since 2003-2004. November 1, 2007. Available at:

  4. Lessler D, Krieger J. From medical system to health system: connecting medical practice to community. PowerPoint presentation.

  5. Robert Wood Johnson Foundation. Improving chronic illness care. Available at:

Clinician–Community Collaborations: A “Win-Win” Scenario

By Steven H. Woolf, MD, MPH
Director, Center for Human Needs
Virginia Commonwealth University

Clinicians play a key role in helping patients to adopt healthy behaviors, but they also face challenges in offering intensive assistance, such as lack of time, skills, and reimbursement. Patients often need extended help because lifestyle change is so difficult.

Systematic reviews demonstrate a correlation between behavior change and the intensity of counseling that patients receive. 1 Although some practices have adopted inpractice solutions such as group visits or delegating behavioral counseling to nonphysician staff educators, the majority of primary care practices in the United States cannot reconfigure themselves to offer intensive behavioral counseling as a regular service.

The innovations presented here offer a promising new model for assisting patients that involves a partnership between health systems and community resources. 2,3 Each example demonstrates an effort to build relationships between clinicians and community programs to facilitate a coordinated approach that helped patients obtain intensive assistance in modifying unhealthy behaviors. In the Community Health Educator Referral Liaisons (CHERL) model, a liaison worked with the practices to make these arrangements. The Virginia Ambulatory Care Outcomes Research Network (ACORN) eLinkS project established relationships with community programs but used the electronic medical record as a tool to facilitate referrals. The Steps to Health King County project featured a county-wide approach grounded in Wagner's Chronic Care Model. 4

Such collaborations offer a “win-win” scenario for clinicians, community programs, and, most importantly, for patients. Patients obtain more intensive assistance, clinicians obtain help in offering services to patients that they cannot provide, and community programs receive clients for which their services were designed. If the approach proves to be more effective than the ordinary counseling offered by clinicians—and early evidence suggests that it might 5 —financing the model may prove to be more efficient and economical for health plans and employers to address tobacco use, obesity, and other risk factors.

Such collaborations do not occur in a vacuum. Substantial legwork and preparation are required to cultivate relationships between clinicians and community programs, which often know little about each other, and to build an infrastructure and functional operating procedures that make it fast and easy to refer patients. Busy primary care practices, community programs, and public health departments typically lack the time, resources, and energy for this legwork. Providing contact information for each other is often the best they can do on their own. Building a more robust and effective collaboration often requires the involvement of a third party. In each of the innovations discussed here, a project team funded by outside sources was the energizing force in establishing the collaboration.

The promise of taking these successful models to scale on a national level therefore requires policy solutions that address financing and resources to support a third party, available in communities across the country, to help link local clinicians with relevant community resources. Collaboration requires other ingredients, such as new models of reimbursement in which payers would recognize the cost-effectiveness of reimbursing counseling provided under these arrangements. It also requires a culture shift, breaking down a century-old schism between medicine and public health and rediscovering their shared interest in promoting good health and reducing the prevalence of unhealthy behaviors.


1 Whitlock EP, Orleans CT, Pender N, et al. Evaluating primary care behavioral counseling interventions: an evidence-based approach. Am J Prev Med. 2002;22(4):267-84. [PubMed]

2 Woolf SH, Krist AH, Rothemich SF. Joining Hands: The Rationale for Partnerships Between Physicians and the Community in the Delivery of Preventive Care. Washington, DC: Center for American Progress, 2006.

3 Etz RS, Cohen DJ, Woolf SH, et al. Bridging primary care practices and communities to promote healthy behaviors. Am J Prev Med. 2008;35(5 Suppl):S390-7. [PubMed]

4 Glasgow RE, Orleans CT, Wagner EH. Does the chronic care model serve also as a template for improving prevention? Milbank Q. 2001;79(4):579-612. [PubMed]

5 Krist AH, Woolf SH, Frazier CO, et al. An electronic linkage system for health behavior counseling: effect on delivery of the “5 As.” Am J Prev Med. 2008;35(5 Suppl):S350-8. [PubMed]

Disclosure Statement: Dr. Woolf has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this article.

Funding Sources

Centers for Disease Control and Prevention


Steps to Health King County

Seattle, WA

King County Steps to Health, coordinated by Public Health–Seattle & King County, was a consortium of more than 75 members, including community-based organizations, health care providers, hospitals, health plans, clinics, universities, faith-based groups, government agencies, and school districts.

Original Publication: 12/08/08

Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last Updated: 07/16/14

Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: 04/16/14

Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read Health Care Innovations Exchange Disclaimer.

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