New York State Department of Health, Center for Environmental Health, Healthy Neighborhoods Program
Ensure Mission-Program Alignment
The HNP framework for asthma management is grounded in a healthy homes approach to hazard prevention and health promotion. The program began with a focus on preventing fire deaths and falls in homes, controlling lead hazards and promoting sanitary conditions. In the late 1990s, based on the strong correlation between traditional healthy homes risk factors and high asthma prevalence, the HNP expanded its portfolio to include asthma assessment, education, clinical referrals and environmental interventions.
Today the HNP provides in-home assessments and interventions to reduce the burden of housing-related illness and injury in high-risk communities. The state health department manages the overall program—bringing the strengths of its surveillance, evaluation and resources, and the program is delivered through grant-funded local health departments, which are competitively selected based on factors including surveillance data on the burden of housing-related disease. The central role for the state provides standardization across core program design elements, such as what housing conditions are assessed and how they are assessed and mitigated, evaluation metrics and a perspective that allows for fast recognition and dissemination of best practices across the program. The locally-led program delivery model allows for tailoring to meet local needs; access to credible, community-based partners; and strong partnerships with local clinical care providers and organizations.
Though all HNP programs follow the same basic program framework articulated by the state—to address tobacco control, fire safety, lead poisoning prevention, indoor air quality and asthma control—specific interventions and staffing models vary from one local delivery program to another. Sanitarians, health educators, certified asthma educators, public health nurses or other public health professionals with training in healthy homes concepts deliver comprehensive assessments and interventions, typically within a single home visit. In about one quarter of the cases, follow up visits are conducted at three to six month intervals with priority for follow-up going to homes with residents with asthma or other pressing health and safety concerns. All local health department partners also receive annual HNP training that includes content on clinical and environmental aspects of asthma, and all local partners are encouraged to build partnerships with clinical providers so that residents with housing-related medical needs can be referred for appropriate clinical care and follow-up. For example, in Niagara County, medical residents regularly accompany HNP field staff on home visits, which provides training for medical professionals on the interaction between housing and patient health while also providing on-site care from a medical professional for patients with asthma. In Schenectady, a public health nurse delivers the home visits and is able to provide enhanced education around self-management during the home visit and to call upon connections with clinical partners to provide follow-up care and case management. In Erie County, the HNP formed a unique partnership with regional managed care plans to identify patients with poorly controlled asthma and integrate the home visit into each patient’s routine case management.
Make It Easy to Support Your Program — Let Funders Support Individual Program Elements
Local programs that receive state HNP funding must demonstrate strong partnerships with other housing and environmental health programs. Because of its multi-disciplinary healthy homes approach, instead of a disease or exposure-specific approach, the HNP is uniquely positioned to leverage support from a diverse base of clinical, environmental and housing partners. This support comes in the form of supplemental funding and donated goods and reciprocal services (e.g., for referrals and case management). Many local programs also attract attention from legislators and private donors interested in supporting their services. Additionally, since evaluation and other management oversight is provided by the state, local programs do not have to support or maintain individual data collection and evaluation systems. The 25-year program history is testament to the value, impact and sustainability of the services it provides to reduce the burden of asthma and other housing-related illness in NYS.
INTEGRATED HEALTH CARE SERVICES — FACILITATE COMMUNICATION ACROSS THE CARE TEAM
Strategic local partnerships improve program targeting to at-risk populations and help integrate environmental management into clinical care. For example, the local HNP in Erie County collaborates with four regional managed care plans to identify poorly controlled asthma patients using hospitalization, ER visit and medication usage data; refer those patients to the HNP for home and asthma control assessments, education and interventions; and communicate the findings of the home assessments back to the referring providers and plans. They also partner to assess the effectiveness and cost of the intervention by tracking pre/post intervention outpatient visits, ER visits, inpatient stays, medication use and associated costs.
TAILORED ENVIRONMENTAL INTERVENTIONS — ASSESS TRIGGER SENSITIVITY AND EXPOSURE
Home assessments include visual assessment of common asthma triggers or conditions that promote triggers and inquiries about asthma symptoms, self-management and knowledge. Participants receive basic asthma education and products, such as mattress covers and green cleaning supplies, referrals (e.g., pest control, code enforcement), and counseling to remediate specific environmental triggers identified during assessments. Triggers and conditions assessed include evidence of smoking, furnace filter conditions, chemical smells and other odors, dust accumulation and clutter, cleaning practices, food and garbage storage, evidence of pests, presence and condition of large rugs, structural disrepair, moisture leaks, presence of mold and presence of pets.
HIGH PERFORMING COLLABORATIONS — COLLABORATE TO BUILD CREDIBILITY
The NYS Asthma Control Program (NYSACP) is a key partner at the state-level for the asthma component of the HNP. The NYSACP assists state Center for Environmental Health staff in providing asthma training to the local HNP delivery programs, reviews asthma data collection tools and evaluation plans, facilitates partnerships with regional asthma coalitions to support the local HNPs and ensures that program content is consistent with the latest NAEPP EPR-3 guidelines.
STRONG COMMUNITY TIES — MAKE IT EASY TO ACCEPT SERVICES
During the design and implementation of one local initiative, managed care program partners were surveyed quarterly so that state-level staff could identify and respond to barriers to care coordination and promote success. For example, when partners noted difficulty in recruiting eligible residents due to fear of retribution from landlords, a paragraph was added to the script used for recruitment to address this concern when it came up during a call.
Evaluation is integral to the HNP. Data is used dynamically to monitor progress and refine the approach. The asthma component uses pre/post-intervention evaluation to assess improvements in the following: presence of triggers or conditions that promote triggers in the home environment; asthma knowledge and self-management—knowledge of triggers and avoidance strategies, medication usage and the use of asthma action plans; and asthma morbidity—number of days with worsening asthma and visits to a doctor, ER or hospital. The state-led evaluation program allows for comparisons across local initiatives to look for the impact of different approaches on targeting the intervention to the most at-risk populations, and the magnitude of improvement in trigger reduction, asthma knowledge, self-management behaviors and asthma morbidity. The state’s central management role in the program helps to ensure that promising and transferable strategies for targeting home visits are shared across local program grantees.
Local programs often collect or acquire additional data (e.g., medical claims data), but the primary data source for evaluation is the HNP four-page dwelling assessment form. The form includes demographic information about the primary respondent; characteristics of the dwelling; characteristics of the residents; physical conditions of the dwelling; and education, referrals and products provided. A one-page asthma form is completed for each resident with asthma at each visit. Completed forms are faxed to the state, which scans the data and saves it in a database. The data system automatically generates quarterly reports for the program as a whole and for individual local health departments.