In Oregon, 9.2% of the adult population has asthma, higher than the national rate of 7.5% (10,11). Approximately 7.3% of Oregon children have asthma, and approximately 2500 asthma-related hospitalizations occur in Oregon each year. Almost 12% of the state's population lives on an income less than the poverty threshold, and 442,000 Oregonians (13%) qualify for Medicaid (12). Among Oregon's population insured by Medicaid, approximately 17% of adults report having asthma (13).

Despite the solid evidence that tobacco smoke is detrimental to the health of people with asthma, data show that 31% of Oregon adults with asthma smoke cigarettes, whereas 23% of Oregon adults without asthma smoke cigarettes (14). Among Oregonians insured by Medicaid, the rate of smoking among adults with asthma is 43% (13). Oregonians who smoke and have asthma report more severe asthma symptoms than Oregonians with asthma who do not smoke. They have more activity limitations, miss more work and school, and seek urgent medical care more often (14).

In 1995, the Health Promotion and Chronic Disease Prevention Program (HPCDP) in the Oregon Department of Human Services began working with the Office of Medical Assistance Programs (OMAP), the agency responsible for administering Oregon's Medicaid programs. OMAP is the largest purchaser of managed care in Oregon and has contracts to administer Medicaid with almost all of the major managed care plans in Oregon. Collaboration between HPCDP and OMAP helped the agencies promote preventive care at the population level. Preventive care interventions developed by HPCDP and OMAP were offered to Medicaid-insured patients in managed care settings, which in 1995 comprised 85% of the population on Medicaid and more than a third of Oregon's overall population. In addition, because most health care providers treated at least some Medicaid patients and belonged to one of these major health plans, joint OMAP–HPCDP initiatives had the potential to reach almost all of the primary care physicians in Oregon.

In 1996, HPCDP created a staff position dedicated to exploring potential areas of collaboration between the agency's chronic disease programs and major Oregon health systems. The person in this position works with health system administrators and data personnel to develop standardized measures of asthma care that can be compared across health systems. HPCDP also provided partial funding for an OMAP staff position dedicated to developing and coordinating chronic disease prevention projects of mutual interest.

The coordinated efforts of the people in the two previously described positions contributed to the establishment of a monthly meeting known as the Quality Performance and Improvement Workgroup. Through this workgroup, representatives from all the contracted Medicaid health plans collaborate on prevention activities as part of their OMAP contract. Activities include implementing physician trainings, developing quality performance measures and quality improvement interventions, implementing tracking systems, developing population-based guidelines, and developing health care policy and service reforms. This collaboration helped catalyze a public–private partnership and a public-health–medical partnership that led to coordinated initiatives promoting chronic disease prevention.

One such initiative was the Tobacco Intervention Project, a partnership involving HPCDP, OMAP, and the Tobacco-Free Coalition of Oregon (15). The project was designed to integrate tobacco-use prevention and treatment into routine health care. It resulted in the statewide implementation of a tobacco-cessation program by all Medicaid health plans. The program included counseling and pharmacotherapy, as well as systematic referral to the Oregon Tobacco Quit Line. The program also included an evaluation component so that health plans could conduct patient satisfaction surveys and chart audits, review relevant administrative claims data to assess the program's effects, and obtain data on numbers of Oregon Tobacco Quit Line calls received from their members. Health plan staff members conducted training and outreach programs for their physicians and provided education and outreach programs to members through mass mailings and other forms of communication (15). These initial collaborative projects have led to several more recent joint OMAP–HPCDP initiatives focusing on tobacco and asthma.

Two HPCDP programs — the Oregon Asthma Program and the Oregon Tobacco Prevention and Education Program — began the statewide Asthma–Tobacco Integration Project in 2003. The goal of the project is to reduce smoking prevalence and secondhand smoke exposure among people with asthma. A primary focus of the project is the development of partnerships among health plans, health care providers, and large health care organizations to integrate asthma management and smoking control through systems innovations and provider education.

One of the strategies for implementing the Asthma–Tobacco Integration Project was to leverage OMAP's investment in tobacco cessation by dedicating HPCDP staff to support OMAP–HPCDP cooperation on asthma management projects, a strategy that had been used previously to promote tobacco cessation. However, because of budget constraints and a hiring freeze, HPCDP was not able to hire new employees. Instead, the state asthma and tobacco programs successfully applied to the CDC's Public Health Prevention Service for a staff member to fill this role. The program sends master's-level, CDC-trained prevention specialists with backgrounds in program management and epidemiology to state and local health departments. This new staff person's duties involve coordination not only between HPCDP's asthma program and tobacco program but also between HPCDP and OMAP.

Discussions between HPCDP and OMAP produced additional tobacco-cessation initiatives at the health systems level. Building on the infrastructure established by the Tobacco Intervention Project, OMAP and its participating health plans decided to target cessation efforts toward its members with chronic diseases. In addition, the health plans in OMAP chose asthma management as a key performance measure for the 2004–2005 fiscal year, partly because of the existence of asthma quality performance indicators developed through a cooperative effort between HPCDP and Oregon's major health plans.

As part of the Asthma–Tobacco Integration Project, HPCDP and OMAP have distributed educational tools and information about tobacco's impact on asthma morbidity to almost all of Oregon's health care providers who serve low-income Oregonians. In April 2004, HPCDP distributed a report on tobacco and asthma in the CD Summary, an epidemiology newsletter that is produced semimonthly by the Oregon Department of Human Services and sent to all physicians and nurse practitioners in Oregon. The report, "Tobacco and Asthma — Enough to Take Your Breath Away," discussed the epidemiology of tobacco use among adults with asthma and provided effective clinical interventions and resources for clinicians (16).

As part of another Asthma–Tobacco Integration Project activity, HPCDP and OMAP staff collaborated to plan and conduct a statewide workshop on asthma management issues for medical directors and quality improvement managers from Medicaid health plans. Such workshops are held twice a year by OMAP. Topics are selected by the OMAP Quality Performance and Improvement Workgroup participants with the purpose of enhancing health plan initiatives. The day-long statewide workshop was called "What Does Good Asthma Care Look Like? The Roles of Health Plans and Providers." Topics included best practices and guidelines that promote high-quality asthma care and the roles of providers, health plans, and the public health field in improving population-level asthma care. The workshop included a speech from a national expert on health system strategies to promote effective asthma management, as well as an expert panel comprised of proponents of asthma-related disease registries, disease management, and other successful asthma-related interventions at the health systems level. The importance of systematically assessing and treating tobacco use in clinical settings was emphasized throughout. Clinical asthma and tobacco tools were provided to medical directors and quality improvement coordinators.

The activities described have led to additional collaborative initiatives to educate and empower health providers and health systems about tobacco control and asthma care. In July 2005, 14 health plans began using an asthma registry (created through a joint effort between HPCDP and the participating health systems) to conduct smoking-cessation activities for members with asthma. The outreach effort involves distribution of materials (previously tested by focus groups) to encourage members who smoke and have asthma to quit, as well as to encourage quitting among plan members who smoke and care for a household member with asthma. The distributed materials contain information about the effects of tobacco smoke on people with asthma, tobacco-cessation assistance, and information about the Oregon Tobacco Quit Line. Health plans are also promoting the Oregon Asthma Resource Bank, a clinically accurate, patient-tested Web site that contains free, easy-to-read, and culturally appropriate asthma education and clinical management tools developed by asthma experts in Oregon.