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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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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Winner Photo Caption: 

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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Asthma Regional Council for their New England Asthma Innovation Collaborative

Winner Blurb: 

Health Resources in Action’s Asthma Regional Council (ARC) established the New England Asthma Innovation Collaborative (NEAIC) in 2012 with a Center for Medicare and Medicaid Innovation (the Innovation Center) Health Care Innovation Award. NEAIC’s goal is to improve asthma outcomes, quality of care, and health care costs, especially for Medicaid and State Children’s Health Insurance Program (CHIP)-enrolled children, by advancing asthma home visits and sustainable payment systems across four New England states: Connecticut, Massachusetts, Rhode Island and Vermont. This goal supports the Innovation Center's aim to achieve better care for patients, better health for communities, and lower costs through improvements to the health care system. NEAIC achieves this goal through asthma self-management education; home environmental assessments, including minor-to-moderate environmental intervention supplies to mitigate asthma triggers; and use of nonphysician providers shown to be cost-effective deliverers of this level of care, particularly community health workers (CHWs) and certified asthma educators (AE-Cs).

 

During NEAIC’s 3 years of Innovation Center funding, providers utilized CHWs and AE-Cs to provide evidence-based home visit assessments and interventions. The target population was pediatric patients (ages 2–17) with poorly controlled or uncontrolled asthma symptoms who had a history of using expensive urgent care, with a focus on high-cost Medicaid and CHIP patients. Patients were enrolled in the intervention for an average of 6 to 8 weeks, with followup at 6 and 12 months after the first home visit. Medicaid payers provided patient claims and encounter data to monitor costs and outcomes for their patient populations, and some will consider new reimbursement policies should the interventions demonstrate positive health and cost outcomes.

 

Broadly, NEAIC focuses on four components: (1) workforce development, (2) rapid service delivery expansion, (3) committed Medicaid payers, and (4) a Payer and Provider Learners Community. Each component builds in continuous quality improvement measures through rigorous data collection/analysis, strong partnerships, and commitments from interested payers and policymakers.

 

In support of a well-trained workforce, NEAIC has provided scholarships for individuals to attend an asthma training institute to increase the number of AE-Cs; they also sponsored core training (a 48-hour course) and asthma home visiting training (a 24-hour course) for CHWs. Both asthma educators and CHWs are considered qualified and cost-effective providers. NEAIC also explored payers’ attitudes, knowledge and beliefs about both asthma home visits and CHWs. These conversations led to recommendations for innovative CHW asthma-credentialing programs that payers and provider practices across New England have requested and can benefit from. These combined efforts should contribute to higher-quality and culturally competent care, and NEAIC believes that the demonstrated cost-effective outcomes will help support innovative Medicaid reimbursement.

 

NEAIC experienced rapid service delivery expansion and provided asthma home visits to 1,145 high-risk children with asthma in its four-state service area during its 3 years of Innovation Center funding. Self-reported data and observations during home interventions show improvements to several intermediate factors, including exposure to environmental triggers, which may explain the improved asthma control and reported decreases in the use of health care services. Findings point to improved quality of life for asthma patients and their caregivers, including a nearly 50-percent reduction in the number of days patients missed school because of asthma and a more than 60-percent reduction in their caregivers’ missed work days.

 

Since its inception, NEAIC has engaged Medicaid payers as partners to provide claims data, participate in regional meetings, and consider financing and policy changes should the service model results achieve the Innovation Center’s aims.

 

The Payer and Provider Learners Community exists to rapidly disseminate demonstrated improvements to the quality and cost of asthma care, share viable reimbursement systems developed, successfully incorporate CHWs into the asthma care team, and disseminate best practices across New England. The Learners Community builds on ARC’s existing networks and partnerships across the region to increase awareness about these successful models, with the goal of broader adoption across New England.

 

Through these four components, NEAIC establishes and promotes CHWs as strong health care delivery partners who address environmental conditions as part of the disease management program—with reimbursement by payers—making this an innovative model for broad dissemination and potential replication across the nation.

 

NEAIC’s Partners

 

Clinical Providers

  • Boston Children’s Hospital (Boston, MA)
  • Baystate Children’s Hospital (Springfield, MA)
  • Boston Medical Center (Boston, MA)
  • Children’s Medical Group (Hamden, CT)
  • Middlesex Hospital (Middletown, CT)
  • Rhode Island Hospital/Hasbro Children’s Hospital (Providence, RI)
  • Rutland Regional Medical Center (Rutland, VT)
  • St. Joseph’s Health Clinic (Providence, RI)
  • Thundermist (Woonsocket, RI)

 

Workforce Development Partners

  • Central Massachusetts Area Health Education Center, Outreach Worker Training Institute (Worcester, MA)
  • American Lung Association of the Northeast (Waltham, MA)
  • Boston Public Health Commission, Community Health Education Center (Boston, MA)
  • Massachusetts Association of Community Health Workers (Worcester, MA)

 

Medicaid Payers

  • BMC HealthNet Plan (Boston, MA)
  • Department of Vermont Health Access (VT State Medicaid)
  • Connecticut Department of Social Services (CT State Medicaid)
  • Health New England (Springfield, MA)
  • MassHealth (MA State Medicaid)
  • Neighborhood Health Plan of Massachusetts (Boston, MA)
  • Neighborhood Health Plan of Rhode Island (Providence, RI)

 

Winnner Photo: 
Winner Photo Caption: 

Marie Gilmond (Rutland Regional Medical Center, VT), Susan Sommer (Boston Children’s Hospital, MA), Veronica Mansfield (Middlesex Hospital, CT), Stacey Chacker (Health Resources in Action), Megan Sandel (Boston Medical Center, MA), Annie Rushman (Health Resources in Action), Elizabeth McQuaid (Hasbro Children’s Hospital, RI), June Tourangeau (St. Joseph Health Center, RI), Michael Corjulo (Children’s Medical Group, CT). Missing from this picture is Matthew Sadof (Baystate Medical Center, MA), Donna Needham (Thundermist Health Center, RI) and Heather Nelson (Health Resources in Action)

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