Greater Providence, Rhode Island is comprised of several urban core cities of high poverty and significant pediatric asthma disparity. The RI-Asthma Integrated Response (RI-AIR) Asthma Care Implementation Program (ACIP) is a comprehensive system of identification, screening, and intervention for pediatric asthma. Core components include: a 1) state of the art technology platform (the RI-AIR information data system, or RI-AIR IDS) to integrate data from LifeChart (EHR), REDCap (research data system), and KIDSNet (state-based database of child health information); 2) algorithm for stratification of asthma management services based on level of asthma control/risk; 3) multilevel school-based education (CASE) to family/child/school system for children whose asthma is not well-controlled; 4) intensive home-based intervention (HARP) for children with poorly controlled asthma; and 5) enhanced coordination between caregiver, school nurse, and health care provider to promote integration across sectors of care.

The first aim of the project is to evaluate the effectiveness of the RI-AIR ACIP using a randomized, stepped wedge design. The second aim involves conducting effective implementation. The third aim involves conducting a mixed-methods evaluation of the sustainability of the RI-AIR ACIP, with ongoing input from our community stakeholders. We plan to demonstrate that RI-AIR ACIP is a replicable, evidence-based, and cost-saving model that improves asthma outcomes for children at most risk, and can be disseminated to other urban communities to address asthma disparities.