DUPLICATION DISTRIBUTION PROHIBBITED AND. Public Health: Model Programs for Advancing Pediatric Asthma Care in Diverse Settings

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1 Workshop 2 Public Health: Model Programs for Advancing Pediatric Asthma Care in Diverse Settings Accreditation UAN L04-P Participation in this activity earns 1.5 contact hours. To receive credit, participants must complete an evaluation form at the conclusion of this session. 1

2 Workshop 2 At the completion of this activity, participants will be able to: Describe program components and outcomes inpediatric Asthma Intervention Care; and Identify opportunities for partnerships in Asthma Intervention programs. Leonard Jack, Jr., PhD, MSc OPENING REMARKS The El Rio Inner-City Asthma Intervention Program REW ARTHUR, MD 2

3 Control of Asthma in a Community Health Care Setting Andrew Arthur, M.D., Ph.D., F.A.A.P. El Rio Health Center Tucson, AZ Matthew Prior Cured yesterday of my disease, I died last night of my physician. 3

4 Asthma Epidemiology Disease Burden Adults Emergency Department 18% (12mo.) Urgent Visit 28% (12mo.) Asthma Symptoms 75% (30 days) Asthma Attack 52% (12 mo.) Sleep Difficulty 51% (30 days) Activity Limited 28% (12 mo.) Asthma Epidemiology Disease Burden Children 5-17 years ( ) 14 million missed school days per yr. 3.7 days per child with asthma per yr. 23% with activity limitation due to asthma Asthma Epidemiology Mortality 2,891 in 1980, (rate 14.4 / 1 million) 5,667 in 1996, (rate 21.8 / 1 million) 4,657 in 1999, (rate 17.2 / 1 million) 4

5 Childhood Asthma Emergency Department Visits During 2008= 29,645 visits Median Charges= $1,027 Mean= $1,409 Max= $33,557 Total charges= $41,767,616 Data from ADHS for Arizona El Rio Health Center Asthma Program Began 2001 with CDC Funding for Inner City Asthma Intervention Program Based on Inner City Asthma Intervention Study (ICAS) model Asthma counselor Initially Children aged 6 12 years In clinic and home-based intervention El Rio Health Center Asthma Program Program expanded with funds from EPA grant and others. Children 5-15 years served Children 3-18 years served after Most years children served. Few adults admitted to program. Dropping of home visits after

6 Asthma Program Patients Served Children 3 years to 18 years of age Moderate or Severe Persistent Asthma Patients registered at El Rio Health Center with established primary care provider Asthma Program Staff Two Asthma Counselors Bilingual On-site availability Asthma Program Components Asthma teaching Allergen skin testing Pulmonary function testing Supplies for home 6

7 Asthma Program Teaching Topics Disease processes in asthma Asthma triggers Controller medications Rescue medications Asthma Action Plan Asthma Program Teaching Method Social Learning Theory (Albert Bandura) Counselor teaches material to patient/family Patient/family teaches material back to counselor to demonstrate mastery Counselor helps patient/family set high level of expectation for control of asthma 7

8 Asthma Program If your child had asthma symptoms 2 days/wk how would you rate his/her control? 8

9 Asthma Program Supplies Education materials Dust mite covers, pillow, mattress Spacers 9

10 Asthma Program Supplies Spacers Asthma Program Intervention and Follow-up Training in clinic Phone follow-up Communication with primary care provider Asthma Program Extra Benefits Patient assistance programs Home aerosol program Advocacy with landlords regarding allergen abatement (carpet, air conditioning, water leaks) 10

11 Asthma Program Results Enroll 100 patients per year Referrals from all 5 El Rio pediatric clinic sites 50% of referred patients enrolled Cost $100K per year Asthma Program Results 2005 School Days Missed 78% decrease Days Sick due to Asthma 92% decrease Albuterol Use 95% decrease Days Exercise Limited due to Asthma 87% decrease Nights of Interrupted Sleep 93% decrease Asthma Program Results 2005 Emergency Department Visits 93% decrease Hospital Visits 78% decrease Prednisone Bursts 92% decrease 11

12 Asthma Program Morgan WJ, et al, NEJM, Vol. 351: MMWR, Feb. 27, 2004, Vol. 53, No. 7 CDC Surveillance Summaries, Mar. 29, MMWR 2002; 51 (No. SS-1) Weiss KB, et al, Annu Rev Public Health, 1993; 14: MMWR, Jan. 14, 2005, Vol. 54, No. 1 Personal communication, Dr. Paul Enright References National Asthma Education and Prevention Program Expert Panel Report 3, Summary Report 2007, U.S. Dept. of Health and Human Services, NHLBI EPA Webinar The Science and Value Behind Targeted Home Environmental Interventions, 10/22/09, Deidre Crocker, et al Communities in Action Knowledge-Base Tailored Environmental Interventions, National Asthma Forum, presentation June 17-18,2010, CDC Report on the Environment, Asthma Prevalence, US EPA, at The HEAL, Phase II Project: Enhancing Features of an Electronic Health Record System to Improve Adherence to Asthma Guidelines KRISTI I. RAPP, PHARMD 12

13 Enhancing Features of an Electronic Health System to Improve Adherence to Asthma Guidelines Kristi Isaac Rapp, Pharm.D., AE C, BCACP, Leonard Jack, Jr., Ph.D., MSc., Jose Flores M.D., Margaret Sanders, M.S.Ed., AE C, Stacey Denham, MSW, MPH, Doryne Sunda Meya, B.S., Alfreda Porter, Pamela Dixon, Candice Wilson, MPH, Robert Post M.D., Nancy Morris Ph.D., Floyd Malveaux, M.D., Ph.D. Center for Minority Health & Health Disparities Research and Education Xavier University of Louisiana College of Pharmacy Asthma Prevalence in Post Katrina Greater New Orleans Area Orleans 12.8% 6,041 children have asthma 19,754 adults have asthma St. Bernard 12.7% St. Tammany 10.7% Plaquemines 10.4% Jefferson 9.9% Louisiana Department of Health and Hospitals, Asthma Management and Prevention Program, Louisiana Asthma Prevalence by Parish, Updated March 2010 HEAL I Overview Implement and evaluate the effectiveness of the combined National Cooperative Inner City Asthma Study (NCICAS) Asthma Counselor Intervention and The Inner City Asthma Study (ICAS) Environmental Intervention NCICAS = Asthma Counselors Only ICAS = Environmental Component Only HEAL I = Asthma Counselors + Environmental Component 13

14 HEAL, Phase II Objectives Extend and build upon the lessons learned from HEAL Phase I. Utilize a partnership model to implement aspects of the Chronic Care Model to address pediatric asthma. Improve pediatric asthma management among patients attending Daughters of Charity Services New Orleans Clinics. Collaboration Key to HEAL, Phase II Success Merck Childhood Asthma Network (MCAN) Catholic non profit healthcare system Primary and preventative care Mdi Medical lhome based on Chronic Care Model Low income population Xavier University College of Pharmacy Center for Minority Health and Health Disparities Research and Education About DCSNO Daughters of Charity New Orleans (DCSNO) Children s Health Fund 14

15 HEAL II to Integrate Best Practices into Existing Structure at Daughters of Charity Services New Orleans Continuous Quality Improvement Patient s Desires & Needs PATIENT CENTRIC SERVICES *More severe or less controlled asthma cases 2/12/2011 Open Access Patient Panels Population Registries PROACTIVE TREATMENT Team Based Care MD Nurse rsecm CMA Pt Care Coordinator Immediate Behavioral Health Consultant DCSNO Clinic Workflow Project Collaboratives Outcome and Results Measures Continuous Quality Improvement 15

16 Asthma Guidelines Guidelines for the Diagnosis and Management of Asthma Expert Panel Report 3 (EPR 3) National Heart, Lung, and Blood Institute (NHLBI) National Asthma Education and Prevention Program (NAEPP) August 29, 2007 EPR-3. Expert Panel Report 3. Guidelines for the Diagnosis and Management of Asthma (EPR ). Bethesda, MD, U.S. Department of Health and Human Services; National Institutes of Health; National Heart, Lung, and Blood Institute; National Asthma Education and Prevention Program, Highlights of Major Changes in EPR 3: Full Report 2007 Four components of Care Component 1: Assessing and Monitoring Asthma Severity and Control Component 2: Education for a Partnership in Care Component 3: Control Environmental Factors and Comorbid Conditions Component 4: Medications New focus on distinguishing between classifying asthma severity and monitoring asthma control New emphasis on approaches to patient education 16

17 EPR-3. Expert Panel Report 3. Guidelines for the Diagnosis and Management of Asthma (EPR ). Bethesda, MD, U.S. Department of Health and Human Services; National Institutes of Health; National Heart, Lung, and Blood Institute; National Asthma Education and Prevention Program, EPR-3. Expert Panel Report 3. Guidelines for the Diagnosis and Management of Asthma (EPR ). Bethesda, MD, U.S. Department of Health and Human Services; National Institutes of Health; National Heart, Lung, and Blood Institute; National Asthma Education and Prevention Program, DCSNO Clinic Workflow 17

18 Asthma Severity Index Expanded Asthma Severity Index DCSNO Clinic Workflow 18

19 Asthma Action Plan Provide to all patients a written asthma action plan that includes instructions for both daily management and actions to manage worsening asthma. EPR Guidelines, 2007 Asthma Action Plan in Electronic Health System (EHS) Prior to using the EMR to generate an asthma action plan, 4% percent of children admitted with an asthma exacerbation received an asthma action plan (AAP) upon discharge. After instituting theemr action plan, 58% percent of children received an AAP. J of Asthma 2008; 45: Moving Towards an Enhanced Electronic Health System for Asthma Existing EHS System Peak Flow Predicted Peak Flow Day Symptoms Night Symptoms Asthma Goals Asthma Action Plan Enhanced EHS System ACT Score Asthma Control Asthma Severity Business Objects utilized to extract data EPR 3 Guideline Elements Assess asthma severity and control 19

20 Key Stakeholders in Planning Process for Enhancing EHS DCSNO Staff Training Discussion between HEAL II and DCSNO Teams EHS changes DCSNO and HEAL, Phase II EHS Experts DCSNO Medical Director Targeted Health Systems Changes Incorporating expanded ASI in EHS Adopting EPR 3 guidelines Enhancing communication among team members Identifying patients for home visits Moving towards routine collection of data Organizational Process Measures Level of control assessed > 80% Level of severity assessed > 80% Completed Asthma Control Test > 80% Completed Asthma Action Plans > 90% Perceptions among providers of whether changes in EMR enhance ability to provide optimal asthma management 20

21 Implications for Clinical Practice Enhancement of an electronic health system can improve guideline based clinical care. EHS enhancements help ensure all patients receive guideline based clinical care. EHS enhancements represent an opportunity for clinics to reach their goal of optimal patient care among all patients regardless of race, ethnicity, income, or insurance status. Questions XAVIER UNIVERSITY S COLLEG E OF PHARMACY Center for Minority Health & Health Disparities RESEARCH EDUCATION An Inner-City Community Asthma Prevention Program in Philadelphia TYRA BRYANT-STEPHENS, MD 21

22 Philadelphia Asthma MCAN Project Phases 1 and 2 Tyra Bryant-Stephens MD, co-pi, The Children s Hospital of Philadelphia Michael Rosenthal MD, co-pi Christiana Care Health Network Vanessa Briggs MBA, Project Director Health Promotions Council Caroline West MPh, Evaluator Philadelphia Health Management Corp Funded by the Merck Childhood Asthma Network Objectives Discuss asthma prevalence and asthma burden in Philadelphia To discuss community multi-system approach to addressing pediatric asthma a in phase 1 Discuss clinical approach in phase 2 Discuss ways to monitor and evaluate program success Asthma Impact on Chidlren 7 million American children have asthma Affects 2 students in every classroom Causes 12 million lost school days Most common health-related cause of school absenteeism 80% have onset by 5 years old 22

23 Disparate Asthma Burden 53% of people with asthma had an asthma attack in 2008 (children>adults). 17% of non-hispanic black children have diagnosis s of asthma. a. Over 8 years ( ) the greatest rise in asthma rates was among black children (almost a 50% increase) CDC Vital signs May 2011 Direct and Indirect Asthma Costs Burden Asthma costs $3,300/person with asthma each year Medical expenses associated with asthma was $50.1 billion in % uninsured people p with asthma could not afford their prescription medicines 59% of children and 33% of adults who had an asthma attack missed school or work because of asthma in Children missed 4 days of school and adults missed 5 days of work because of asthma. CDC Vital signs May 2011 Asthma Prevalence 23

24 Target Populations West, Southwest, South, and North Philadelphia Urban, poor, predominately African-American and Latino communities CAPP s Outreach from present Broad Goals of CAPP (founded in 1997) To increase asthma knowledge and improve asthma self-management behavior To improve quality of life for children with asthma To equip members of the community to become neighborhood asthma experts To promote asthma-safe home and school/child care environments To reduce burden of asthma on disparate populations in Philadelphia 24

25 Project Partners for MCAN phase 1 The Community Asthma Prevention Program(CAPP), The Children s Hospital of Philadelphia Health Promotions Council The Philadelphia School District Healthier Futures- Child Asthma Link Line The Philadelphia Department of Health Philadelphia Health Management Corporation Thomas Jefferson University Hospital Goals of MCAN phase 1 Improve access to and quality of asthma health care services for children; Improve knowledge about asthma among affected individuals and the general public; Make communities and schools more asthma-friendly; Promote asthma-safe home environments; Reduce disparities in childhood asthma outcomes. Designing a Multi-Pronged Intervention- Things you need to know How bad is the asthma problem in the targeted area? How do you improve the outcomes for children with asthma? What are and where are the solutions to the asthma problem? What are the resources in the community? How do you connect children with asthma to the resources? 25

26 West, Southwest, South, Northwest and lower Northeast Philadelphia 2-18 year olds Long-Term Outcomes Increased symptom control for children in targeted interventions Reduced asthma morbidity MCAN PROJECT MODEL 26

27 Community Asthma Interventions Community Intervention Conduct Door-to-door asthma screenings Methodology Used Brief Pediatric Asthma Screen Divided high prevalence neighborhoods into block groups Randomized into four-block radius CHW conducted screens Opt out phone number given Outcomes Prevalence data Case identification Coordination of asthma-related health services Community Classes Methodology Held at community sites for caregivers of children with asthma 3-5 weekly sessions Outcomes Pre/post knowledge Asthma control (perceived parental) 27

28 Home Asthma Education and Environmental Intervention Community Health Worker implements intervention Targets child bedroom and living area Includes all asthma classes + environmental intervention Common triggers: dust, cockroach, mice, mold, tobacco smoke Supplies include: mattress/pillow covers, mold prevention, tobacco smoke reduction Schools After Before Home Asthma Education and Environmental Intervention Outcomes Reduced indoor asthma triggers (pre/post) Symptom control (pre/post) beta agonist use (pre/post) missed school days and missed parental work days (pre/post) Improved quality of life (pre/post) 28

29 School Intervention Four interventions: School asthma screening Staff development through asthma education programs for teachers and staff Asthma education for children and families through asthma clubs, and asthma awareness days Use of the Asthma Action Plan (AAP) School Screenings Purpose Case identification and linkage with services Establish school asthma prevalence rates Methodology Screening packets distributed to classes Children took to caregivers to complete Children and teachers incentivized for return of screening documents Other School Outreach Activities Integrate asthma education into health curriculum Increased knowledge School professional training Adopt modified Tools for Schools Reduced asthma triggers in schools Asthma Kid Clubs 29

30 Child Asthma Link Line Intervention Methodology Asthma care coordinators staff telephone line to coordinate medical appointments, asthma education, home visits, housing and insurance assistance, and other services that parents may need to help their children with asthma. Baseline needs assessment Outcomes tracked Improved access to health services at 6 months, including health insurance Increased identification of pcp Quality of life- pre/post Presence of asthma medications and asthma devices- baseline/post Provider Trainings The Physician Asthma Care Education (PACE) Seminar provides physicians with information on: the National Guidelines for diagnosis and management of asthma, new asthma medications and treatment strategies, patient communication techniques, and billing strategies for asthma education and procedures. Outcomes Increased knowledge (pre/post) Increased use of AAP (pre/post) Increased use of severity classification (pre/post) Outcomes 30

31 Community Asthma Classes 12 Series Completed 140 participant completing classes (200% of goal) Additional series scheduled for Summer of 2009 (sustainability). Results of Classes Door to Door Screening Results Asthma Prevalence in West and North Philadelphia n=2368 Positive 22% Probable 5% Negative 73% 31

32 Screening Schools Completed Screening at 16 out of 16 Target Schools Total Number of Children Served by Target Schools: 8,514 Average Response Rate: 62% Asthma School Screening Results- (70% response) Negative 56% N=5563 Positive 27% Probable 17% School Professional Training Outcomes PY 4 School Outreach and Education 36 SDP Nurses trained using NACE 47 teachers trained through staff development programs 4 Open Airway Programs students 32

33 Home Environmental Interventions Home Asthma Education and Environmental Intervention Demographics of Home Visit Families N= 208 children Mean Age years, ± 4.2 Sex 54.0% male Race 83.8% African American Ethnicity 13% Hispanic Baseline Characteristics All Clients n=365 HOME ENVIRONMENT CHARACTERISTICS Type of Dwelling Row house 69.6% Type of Housing Rent 62.1% Gas Heating 87.9% Forced Air Heating 52.8% Ever used for heat: Gas stove 10.6% Electric space heater 28.8% In TV/Living Room: Air conditioner 50.9% Upholstered furniture 78.3% Wall-to-wall carpet 53.1% In Child s Bedroom: Wall-to-wall carpet 54.6% Pillow-covers 2.1% Mattress cover 2.8% Blinds, curtains, drapes 84.9% Stuffed animals 55.6% Air conditioner in window 35.0% Clutter on floor 65.1% General assessment of child s bedroom Poor 5.6% Fair 89.6% General assessment of home Poor 16.1% Fair 75.0% Smoker living in the home 38.6% Furry pets in the home 47.5% 33

34 Home Visit Environment Intervention Results Baseline n=195 Follow-up n=195 Number of 3.78 (±1.37) 3.50 (±1.46)* Triggers Present in the Home Number of Remediation Steps Taken *P < (±2.16) 5.05 (±1.08)* Home Asthma Education and Environmental Intervention Outcomes Paired Analysis n=208 Baseline 12 month p- value ED visits last 12 months 2.04(±1.43) 1.04(±2.13) <0.05 Hospitalizations last 12 months.90(±2.11) 0.39(±1.04) <0.05 Missed school for any reason 7.13(±11.47) 6.13 (±7.97) 0.49 Missed school for asthma 5.85 (±10.46) 4.02 (±6.44) <0.05 Home Asthma Education and Environmental Intervention Outcomes Paired Analysis n=208 Baseline 12 month p-value # of days using rescue meds <0.05 (±4.58) (±3.55) # of days with symptoms 3.17(±4.25) 1.71(±2.92) < # nights with symptoms 2.82 (±4.22) # of days child slowed down because of asthma 1.44 (±3.29) 2.90 (±4.83) 1.00 (±2.13) <0.05 <

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36 Common themes of interventions Utilization of a participatory process Utilization of Community Health Workers Importance of Community stakeholders Identification of Asthma champions Finding Strength in the community Finding resources in the community Connection/linkages to resources in the community Assuring Data collection integrity Evaluation of Outcomes Sharing outcomes with partners is important Consider your partners/participants experts in their own right Lessons Learned CHWs are great recruiters for the project CHW s can build valued supportive relationships with caregivers Establish boundaries for CHWs and clients Educate CHW s about legal ramifications Important to recruit CHW s who have some experience in building relationships with clients 36

37 Five C s of Recruitment Communication- peer-to-peer; CHW- toprovider; CHW-to-school nurse Community- involve in design and recruitment e t Convenience- schedules and interventions Compensation- for their time Contact- get three! Lessons Learned Data collection has to be monitored closely Review essential data elements consistently Create script for interviewers when asking questions Have CHW s monitor each other at monthly/weekly meetings Do random chart checks Create punch list for data entry clerk Expectations must always be inspected Important to celebrate with the families Lessons Learned Difficult to sustain entire project but able to build capacity in individuals and community organizations Schools have many competing priorities and it s important to have a champion on the inside Screening, although controversial, is important to establish how prevalent the disease is, where services are needed, who is most affected by asthma until a tracking/surveillance system is established. 37

38 Summary/Conclusions The Philadelphia MCAN project Phase 1 was a comprehensive community-wide attempt to reduce the burden of asthma which was ambitious in its scope, but ongoing Partnerships were essential to the success of the project Although sustainability is difficult, capacity built within the partnerships and individuals enable them to be more effective in controlling asthma and reducing the burden of asthma in disparate populations Primary Care Office Education Project Methods Asthma champions (nursing staff and practitioners) Site-specific Participatory process- practice chose which level Lessons Learned Baby steps Make things easy Team effort Each practice has a different culture 38

39 You Can Control Asthma Navigator Project-Phase 2 Tyra Bryant-Stephens, MD Cannae Dirl, MSW Project Manager Charmane Braxton, Asthma Care Navigator Carmen Perez, Asthma Care Navigator Caroline West, MPH, Evaluator YCCA Navigator Program Hybrid Model Yes We Can + Patient Navigation Both the clinical and social environment of the patient and family is addressed through provision of patient centered asthma care, asthma education, home visits, and social support We hypothesize that this will result in improved self-management skills for caregivers and patient resulting in better asthma control. Study Design Prospective case-matched control design based on criteria: Patient at one of the four CHOP CARE urban primary care sites Birth month and year Gender Ethnicity Medicaid Insurance Case enrollment month and year. If no match based on enrollment month and year, then match will be based on mo/yr +/- one month. Number of Emergency Room Visits and Inpatient visits one year prior to enrollment 270 enrolled 20% attrition 216 for final analysis 39

40 Asthma Care Navigator Care Coordination- Integration of Medical Home with the Community Methodology Use of chronic care model Redefining the health care team Asthma Navigators- Community Health Worker is central health liaison Caregivers- Enabling them to find the best way to manage the asthma care for their children Closing the circle of care Lessons Learned To be continued Outcomes Primary Outcomes Improved asthma control Improved # of follow-up appointments Reduced emergency visits Reduced inpatient visits Secondary Outcomes Improved pulmonary function Improved caregiver knowledge Reduced missed school days Reduced missed parent work days 40

41 CAPP is founded by Dr. T. Bryant- Stephens in response to high incidence of asthma ED visits in her practice. strategies include CAPP expands community Home Visits education,, and program in West. training South, & Southwest community Philadelphia (EPA). leaders Home Visits added. Classes and and Train-the-Trainer are implemented Community Controlling Asthma in Advisory Board American established Cities project implemented over five years CAPP receives NIEHS EJ award for West Philadelphia CAPP Collaborative is formed. The four-prong approach includes: Home Visits, Community Classes, PCP Training, and School Interventions. Smoking Cessation Counseling added to CAPP. Merck Childhood Asthma Network Funds school, home and community interventions Door-to-door and school screenings EPA funds EMR PCP education MCAN funds Asthma Health Navigator Program Presented at the Xavier of Louisiana College of Pharmacy's Fifth Health Disparities Conference March 6-8, 2012 New Orleans, LA Sustainability Build sustainability in your plan using the current infrastructure as much as possible Start thinking of sustainability from the beginning Encourage/Urge your community partners that they need to think about sustainability with you throughout the process Look for partners within your organization with whom you can combine your strengths It always requires some source of funding Summary CAPP has successfully conducted a variety of community based projects in a variety of settings Whereas community research and programming is not clean it s feasible and effective Most people are interested in learning and improving outcomes for children with asthma Each partner has something to bring to the table Acknowledgements-CAPP Staff Sherry Biggs Charmane Braxton Beverly DesVignes Cannae Dirl Barbara Dion Tish Hess Michelle Jackson Cizely Kurian Galen Laprocido Carmen Perez Zalika Shani Phyllis Slutsky 41

42 Thank you Questions? Panel Discussion QUESTIONS ANSWERS Thank you for your participation! 42