Community in Action

Community Asthma Prevention Program at The Children’s Hospital of Philadelphia

Winner Blurb: 

The Community Asthma Prevention Program (CAPP) at the Children’s Hospital of Philadelphia (CHOP) serves low-income and under-resourced communities in Philadelphia, Pennsylvania, which have high asthma prevalence and hospitalization rates. Since its inception, CAPP has focused on fighting these disparities in childhood asthma and providing asthma self-management education in all sectors of a child’s life, including the home, community, school and health care environments.

Medical Director Dr. Tyra Bryant-Stephens leads a staff of 12 that includes a registered clinical nurse, educational coordinators, asthma navigators and lay home visitors. Coordinators oversee the programs and develop connections within the community to teach community asthma classes. The program equips families with asthma self-management education, in-home assessments for asthma triggers, remediation supplies, and connections to community-based resources to improve children’s asthma.

CAPP pursues and maintains strong partnerships to address asthma disparities in schools, homes and the community at large. CAPP’s partners include parents, the public school system, primary care providers, the public health department, managed care organizations and faith-based organizations. Building on this foundation, CAPP is now utilizing community health workers (CHWs) to connect the home, community, school and health care sectors in a research project funded by the National Heart, Lung, and Blood Institute. CAPP’s CHWs are currently among the few nationwide who are reimbursable by health insurance companies.

Twenty years after its founding, CAPP has served more than 4,000 families and conducted approximately 20,000 home visits, primary care education for more than 21 practices, asthma education for numerous school professionals, and school-based student asthma classes in Philadelphia and the surrounding area. The program has reached about 30 percent of the West Philadelphia community’s asthma population. In an evaluation of 2010-2014 data, CAPP’s program success realized a 62% reduction in emergency visits and a 70% reduction in hospitalizations.

The Philadelphia CAPP program’s success has sparked relationships beyond Philadelphia. In 2017, the Pennsylvania Department of Health, a long-time funder, requested that CAPP expand its reach to the city of Pittsburgh, Pennsylvania. Although this project is in the initial phase, stakeholders are confident that the CAPP model will have positive outcomes within this new target area.

The significance of CAPP’s work afforded the director the opportunity to participate in a roundtable discussion with President Barack Obama on climate change and public health in 2015.

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The Community Asthma Prevention Program at The Children`s Hospital of Philadelphia

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Esperanza Community Housing Corporation

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Esperanza Community Housing Corporation (Esperanza) serves the communities located in South Los Angeles, an area that is home to almost one million residents and one of the most economically disenfranchised areas in the County of Los Angeles.  Founded in 1989 out of a successful community organizing campaign to prevent the displacement and housing vulnerability of tenants, Esperanza has grown to become a national leader in advancing the Promotores de Salud (Community Health Promoters)  Model  in targeting health disparities, improving health, and increasing access to health services for community residents.  Since 1995, Esperanza has trained and mobilized 474 Promotores de Salud, through an intensive 6-month training, to provide culturally accessible primary prevention, health education  and advocacy services to families and children in South Los Angeles.  In 1998, Esperanza began cultivating its Healthy Homes collaborative to address primary prevention of lead poisoning and other housing-based hazards,  in a multi-layered approach to mitigating environmental health hazards in the home.  Recognized as a National Healthy Homes Leader, Esperanza established the Healthy Breathing Program which uses a Healthy Homes approach in its home-visitation model to focus on the identification of asthma triggers, iterative health education, and management of asthma episodes in the home.  

 

Along with their team of Promotores, Esperanza’s Healthy Breathing Program partners with federally qualified health centers, local hospitals, and clinics to provide comprehensive services to asthma patients throughout the year.   Esperanza’s Healthy Breathing Program features repeated in-home visits and a year-long patient evaluation; identifies and helps control in-home asthma triggers; and, provides in-depth asthma education for patients, household members, and caregivers.  The program strives to enroll at least 500 pediatric and adult asthma patients every three years.  These efforts have led to improvements in prescription adherence, increases in the number of patients with asthma action plans, reduction in severe asthma episodes, and more efficient referrals to medical homes and wrap-around services.  The Healthy Breathing Program provides valuable cost savings by reducing the number of unnecessary emergency room visits.  A 2012 analysis of a single emergency department saw more than 1.4 million dollars in savings by utilizing preventative in-home and outreach education. 

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Healthy Breathing Team Members (Left to Right): Consuelo Pernia, Destinee DeWalt, Maria Bejarano, Amelia Fay-Berquist and Ashley Lewis.

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Public Health—Seattle & King County

Winner Blurb: 

During its 20-year history, the King County Asthma Program (KCAP) at Public Health—Seattle & King County has pioneered research and programs in asthma management. Under the guidance of Dr. Jim Krieger, KCAP developed its core programming: home visits with community health workers (CHWs) to reduce asthma triggers in homes and improve asthma outcomes. For 20 years, KCAP’s projects and research have helped build the solid evidence base for this model, which now informs asthma services offered across the nation. To build this program, KCAP program staff have worked with care providers in public health settings, hospital systems, community clinics, health plans, schools, housing agencies and community organizations. Since its original demonstration project began in 1997, KCAP has engaged more than 4,000 patients in programs to manage environmental asthma triggers and improve care delivery for better health outcomes.

 

Building on a deep history of providing asthma services to those most in need, KCAP’s current Guidelines to Practice (G2P) project focuses on coordinating care and services for low-income clients with poorly controlled or uncontrolled asthma, specifically for King County’s African American, Hispanic and Somali communities. These communities are disproportionately affected by asthma and more likely to live in housing that exposes them to asthma triggers. Funded through a grant from the Patient-Centered Outcomes Research Institute (PCORI), G2P is KCAP’s most robust program to date. The program coordinates care between the patient, the patient’s health care provider and the patient’s health plan. Experienced CHWs work with patients in their homes to reduce asthma triggers; they also provide case management, support, supplies and resources to help patients self-manage their asthma. Working with several clinics and health plans, KCAP has developed an enhanced electronic health record template that streamlines communication between CHWs, care providers and health plan managers, making it easier for patients to access care. The three care teams are now able to work from a shared asthma care plan.

 

KCAP’s four CHWs have extensive experience working with individuals to improve health outcomes. Some have backgrounds in social work, medical assistance and medical interpretation, but their strongest experience is their deep familiarity with the communities they serve. CHWs have social and cultural connections and shared life experiences with their clients, which helps ensure that KCAP’s care delivery is culturally relevant. The program currently enrolls clients, both adults and children, to receive up to three home visits from a CHW. Each home visit consists of a home environment assessment, assistance with the identification and management of asthma triggers, and a discussion about medication concerns and adherence. The CHW sets self-management goals and provides practical tools to reach those goals, including a free High-Efficiency Particulate Air (HEPA) vacuum; HEPA air filters for high-risk patients; allergen-control bed covers; food storage containers; green cleaning kits; and an asthma spacer, peak flow meter and medicine boxes.

 

Many clients face pressing stressors that overshadow asthma as a concern, such as poor housing conditions, housing instability and mental health issues. Although CHWs emphasize asthma management, they can coordinate additional services so that these patients can begin to focus on their asthma. CHWs can connect patients with KCAP’s partners and local agencies offering other clinical and social services. The CHWs’ ability to provide culturally competent, empathetic approaches to the many social and environmental causes of asthma have been a cornerstone of KCAP’s success in asthma care for the past 20 years. KCAP’s programming is expanding to include additional partners that can more directly offer clients asthma-related services. These programs include housing weatherization and repairs specific to respiratory disease, tenant advocacy and legal resources, child care consultation, and training for pharmacists on medication adjustment.

 

In addition to working with clients in their homes, KCAP’s current program works with care providers and health plans to change systems and improve delivery of services in the community. KCAP is working with 13 clinics and two health plans to improve clinical care guidelines; equip clinics with spirometry and allergy testing; and optimize electronic health records to improve communication and care coordination between care providers, patients, CHWs and health plans. It also is working with two health plans to improve their Medicaid Managed Care Plans, adding such components as enhanced case management, medication monitoring, and provider notification of emergency room visits or hospital discharge.

 

KCAP’s extensive body of work in environmental asthma management and care coordination is evident in the successful patient outcomes throughout the program’s history. KCAP’s pioneering efforts with the CHW model and care coordination have contributed to decreases in asthma-related hospitalizations and urgent care use, increases in patient and caregiver quality of life, and a greater overall return on investment when compared to standard care. KCAP continues to build the evidence base for the CHW model and patient-centered asthma care, and it serves as an exemplar for asthma care delivery across Washington state and nationwide.

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Over 20 years, King County Asthma Program’s (KCAP) Community Health Worker programs have reached over 4,000 patients in programs to manage environmental asthma triggers and improve care delivery for better health outcomes. Above, CHWs, program staff, and project partners from KCAP’s Guidelines to Practice project.

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