Background: The majority of adults with persistent asthma have chronically uncontrolled disease and interventions to improve outcomes are needed. We evaluated the efficacy, feasibility, and acceptability of a multi-component smartphone-telemedicine program (TEAMS) to deliver asthma care remotely, support provider adherence to asthma management guidelines, and improve patient outcomes. Methods: TEAMS utilized: (1) remote symptom monitoring, (2) nurse-led smartphone-telemedicine with self-management training for patients, and (3) Electronic medical recordbased clinical decision support software. Adults aged 18-44 (N ¼ 33) and primary care providers (N ¼ 4) were recruited from a safety-net practice in Upstate New York. Asthma control, quality of life, and FEV 1 were measured at 0, 3 and 6 months. Acceptability was assessed via survey and end-of-study interviews. Paired t-test and mixed effects modeling were used to evaluate the effect of the intervention on asthma outcomes. Results: At baseline, 80% of participants had uncontrolled asthma. By 6-months, 80% classified as well-controlled. Improvements in control and quality of life were large (d ¼ 1.955, d ¼ 1.579). FEV %pred increased 4.2% (d ¼ 1.687) with the greatest gain in males, smokers, and lower educational status. Provider adherence to national guidelines increased from 43.3% to 86.7% (CI ¼ 22.11-64.55) and patient adherence to medication increased from 45.58% to 85.29% (CI ¼ 14.79-64.62). Acceptability was 95.7%; In follow up interviews, 29/30 patients and all providers indicated TEAMS worked better than usual care, supported effective selfmanagement, and reduced symptoms over time, which led to greater self-efficacy and motivation to manage asthma. Discussion: Based on these findings, we conclude that smartphone telemedicine could substantially improve clinical asthma management, adherence to guidelines, and patient outcomes.

Rationale: School based medical management of asthma is being increasingly used to combat uncontrolled pediatric asthma and increase adherence to controller medications. However, little is known about asthma management challenges in the context of school-based care. Objective: The purpose of this study was to explore multi-level perspectives of school-based asthma management, with a focus on understanding goals, barriers, facilitators, and perspectives of school-based asthma care. Methods: Focus groups and interviews were conducted with 67 participants representing the entire school-based asthma care community (child/caregiver, school personnel, nurses, pharmacists, healthcare providers, and administrators/insurers). Qualitative descriptive and data mapping techniques were used to analyze data. Results: Goals: Children/caregivers prioritized the ability to live a normal active life and minimize worries about asthma. Other stakeholders prioritized keeping the child out of the emergency room and minimizing lost learning time. At times, these differences in goal priority caused conflict between groups, and in some cases, goals attributable to professional role, such as reducing healthcare costs, conflicted with an individual's personal/moral objectives of providing better care. In general, participants reported that school-based asthma management was beneficial but that the full benefits could not be realized due to multi-level systems challenges. Nearly all the facilitators identified by participants were directly attributable to formal school-based asthma care programs, whereas barriers typically emphasized systemic and contextual challenges, such as lack of resources, time, and training (TABLE 1). Facilitators: The most commonly identified facilitators were continuity of care, strong relationships between care community members, and incentivizing for outcomes. School-based asthma management was viewed as a strong facilitator, but only if there was a full-time school nurse. Barriers: Four themes were identified. (1) There is insufficient systems and policy support for asthma management in general and at school in particular. (2) Overburdened families and systems operate in crisis-mode; asthma management is not a priority until crisis is reached. (3) Wide-spread discordance and distrust between members of the asthma care community hinders shared asthma management. (4) This is attributable in part to communication challenges at all levels. Conclusion: Moving away from a crisis-based approach to asthma management will require increased systems resources and support to facilitate proactive asthma care and addressing discordant relationships and communication challenges at all levels of the asthma care community. These findings highlight the importance of addressing contextual factors, which can impact broader uptake, efficacy, and long-term sustainability of school-based asthma interventions.

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