Community in Action

Multnomah County Health Department partners with organizations at the national, state and local levels to deliver a multi-component healthy homes program across Portland and Multnomah County, Oregon.

The Healthy Homes Program developed as a result of a community assessment which was guided by the efforts of a community-based environmental health coalition. The coalition was comprised of a network of 45 community-based organizations, local agencies and public officials and was instrumental in developing and implementing a community-based environmental health assessment to identify community environmental health concerns. The goals were to identify environmental health issues, prioritize issues, develop action plans and evaluate the progress to address selected issues. 

The assessment data and results became the impetus for developing the Healthy Homes Asthma program and focusing on improving indoor air quality and reducing asthma triggers in the homes of low income families with children with asthma. The Multnomah County Environmental Health Services (MCEHS) sponsored the Healthy Homes Coalition, which emerged from the Summit with a goal to address environmental factors that affect asthma and other health conditions by prioritizing substandard housing and housing codes.

The work of the coalition resulted in the successful submission of a grant to the Department of Housing and Urban Development (HUD) Healthy Homes program in 2005. With HUD funding, MCEHS began delivering in-home nursing case management, environmental assessments, behavioral interventions and supplies to reduce asthma triggers for low-income families of children with asthma. In addition to direct care services, the program also focused on policy development, housing code enforcement, integration with clinical providers, and connections to remediation and community support resources.

MCEHS initially developed the Healthy Homes Program for low-income children with asthma who received primary care at county health department clinics. In 2009, MCEHS developed an Asthma Inspection and Referral (AIR) program, a one-time home inspection program for any child with asthma, regardless of income. AIR augmented the more in-depth Healthy Homes program, which targeted low income and less controlled children with asthma. Over time, the Healthy Homes Program broadened its services, developing the Community Asthma Inspection and Referral (CAIR) program funded by a HUD Demonstration Grant, to deliver home assessments to an even broader group of children with asthma and other environmentally related health conditions. Referrals to the Multnomah County Asthma programs now come from clinic providers and other community organizations throughout Multnomah County. Through a web based referral system the programs were able to accept referrals from community medical providers, community based organizations and other partners through-out the county. MCEHS and its growing group of partners continued to expand the services and reach of the Healthy Homes to include Healthy Homes, AIR, and CAIR. Working in collaboration with other community partners such as the City of Portland, they seek to address asthma at the individual, family, organizational, community and public policy levels to improve outcomes for all children in the county.

MCEHS' Healthy Homes program is available to low-income families and prioritizes children with uncontrolled asthma who have had recent ER visits, or who are prescribed inhaled corticosteroids. Healthy Homes positions a Community Health Nurse (CHN) as the child's case manager and a Community Health Worker (CHW) to help manage the home environment. Together, they conduct approximately seven home visits and provide ongoing telephone support. CHNs receive referrals, review cases and consult with providers. During home visits, CHNs focus on assessing asthma severity and control, reviewing medication, and developing individualized asthma care plans. CHWs work with families on environmental assessments and interventions. Both CHWs and CHNs link families to support resources; CHNs link to medical services and consult with the medical team and pharmacy, while CHWs connect families to remediation and other services.

Over approximately six months, Healthy Homes program CHWs provide customized assistance in implementing the Family Action Plan. Assistance consists of in-home and telephone support, education ,behavioral interventions, skill-building demonstrations and providing supplies, such as green cleaning kits, vacuum cleaners with HEPA filters, allergen-free bedding encasements, door mats, bed frames and linens. In addition, families may be given basic maintenance items such as batteries for smoke detectors, furnace filters or new smoke detectors. Client assistance items average $336 per family.

With the expansion of the initiative to add CAIR, providers and social service agencies began to use a Web-based system for referrals, charting, and reporting. In AIR an Environmental Health Specialist (EHS), performs a single environmental assessment. If appropriate, he might refer clients directly into Healthy Homes or CAIR. CAIR program staff included two CHWs who served as case managers. They conducted environmental assessments, basic interventions, addressed behaviors and make referrals. Physical and structural remediation concerns were referred to the EHS who was able to leverage services for home repair. Uncontrolled health issues were referred to the CAIR CHN.

The Healthy Homes program has collected outcomes data since 2005, and the CAIR program has collected data since its inception in 2010. Both Healthy Homes and CAIR programs tracked environmental assessment scores, asthma control test (ACT) scores and ER visits.

The Healthy Homes program has demonstrated a 2.5 times reduction in the use of ER and significant reduction in hospitalizations for children with asthma who have completed the program. In addition, the Healthy Homes intervention is associated with a statistically significant reduction in the number of environmental observations of asthma triggers in both Healthy Homes and CAIR. Finally, 75 percent of Healthy Homes' clients showed improved ACT scores over a six month period. Based on a 2008 evaluation conducted in partnership with Care Oregon, the managed care plan that served 99 percent of Healthy Homes' participants at the time of the evaluation, the program resulted in almost $350,000 in savings from avoided health care utilization (i.e., avoided hospitalizations and ED visits).

To sustain the program, MCEHS advocated for direct reimbursement from the State of Oregon. In 2010 MCEHS negotiated with Oregon Department of Medical Assistance Programs and Center for Medicaid Services, CMS to develop Healthy Homes targeted case management, allowing for Medicaid reimbursement. In addition, the Healthy Homes Coalition continues to seek to embed environmental solutions for asthma in the housing code, improve substandard housing and advocate for tenants.

The North East Independent School District (NEISD) is a large urban district that serves 67,000 students, including more than 8,000 with asthma. In 2006, NEISD hired a registered respiratory therapist/certified asthma educator (RRT/AE-C) to launch an asthma management program to improve students’ asthma control and attendance in order to positively contribute to the district’s academic performance.

NEISD’s investment in the Asthma Awareness Education Program (AAEP) reflects its leadership’s recognition that asthma control is fundamental to student achievement. The AAEP’s evaluation data have demonstrated that comprehensive school-based asthma management programs can improve disease management, reduce emergency health care utilization, and increase school attendance, thus impacting academic performance and generating a return on investment. In Texas, as in a handful of other states, average daily attendance rates are at the foundation of the state’s formula for distributing school revenue. An effective school-based asthma control program like NEISD’s can quickly increase attendance and thereby pay for itself.

The AAEP provides education, disease management tools, and other support to help school nurses identify and monitor students with asthma and to improve communication with clinical staff. NEISD also provides case management services for children with hard-to-control asthma, including RRT/AE-C-led home visits, personalized counseling and coordination with asthma specialist physicians. The Asthma Blow Out (ABO) is the AAEP’s community engagement component, which is delivered in areas with the largest disparities in asthma outcomes. The ABO brings RRT/AE-Cs and physician partners to local schools where they explain disease management strategies and medication use, dispense flu vaccines and provide age-appropriate asthma education to students, parents and caregivers. To decrease healthcare barriers, where indicated, NEISD provides bus transportation to and from the schools, free meals, English-Spanish translation services, and offers academic incentives for students to attend the ABO events.

The AAEP addresses environmental asthma triggers in schools through training for custodial staff, principals and teachers, as well as through monthly meetings with facilities staff. The district also incorporates an asthma management component in the high school’s Healthy Lifestyles course; has implemented an air quality health alert policy to ensure the campus community knows when unhealthy outdoor air conditions occur; and conducts regular monitoring of asthma symptoms and possible environmental exposures in schools. The AAEP also promotes environmental asthma management at home.

In the six and a half years since the program’s launch, the AAEP has reduced asthma symptoms in school as measured by declines in rescue/reliever medication use. For example, inhaler use declined by 50 percent during the first six weeks of school from the first year to the next. Emergency medical service transports during the school day also decreased from 80 transports per year to 24 transports per year. The AAEP has delivered asthma education to every district campus by reaching every physical education teacher, nurse and campus administrator. ABO survey results also demonstrate improved student and parent understanding of appropriate asthma management strategies – 95 percent of parent attendees surveyed said they would recommend the ABO program to a friend. Additionally, the district has seen yearly attendance averages increase from 95.3 percent to 96.1 percent since the AAEP’s inception, including significant increases during flu season. NEISD has achieved state recognition for its academic performance four years in a row. There is widespread agreement that the AAEP-led environmental improvements and involvement in student health contributed to improved student performance and the district’s academic accomplishments.

In the mid-90s, the Michigan Department of Community Health (MDCH) recognized asthma as a growing health problem, especially among low-income children and populations with economic, race and access disparities. As MDCH geared up to increase asthma awareness in these disproportionately affected communities, it quickly determined that a coordinated effort would ultimately have the greatest impact on health outcomes.

Therefore, in 2000, MDCH brought together more than 125 asthma experts to develop the first statewide plan to address asthma in communities bearing the highest burden. This successful collaboration lead to the creation of the Asthma Prevention and Control Program (APCP). 

The APCP, which provides expertise and long-term guidance for asthma quality improvement activities, has aided in the development and impact of many successful community-based asthma management programs across the state, such as Managing Asthma Through Case-management in Homes (MATCH). This program utilizes a combination of home, school and work visits; asthma action plans; and Medicaid reimbursement to provide long-term interventions and care for individuals with asthma. MATCH participants reported significantly fewer emergency room visits and hospitalizations, and had significantly shorter lengths of stay, if hospitalized due to asthma.

Recognizing the success of the program, APCP helped to replicate this model in other communities, and as a result, has more than doubled the number of people served by MATCH. Surveillance data and input from strategic partners have been key components to this success and are used to continuously measure both the state’s and community’s needs and to ensure that any changes in asthma burden result in adjusted programming.

Between 2000 and 2007, APCP’s efforts have contributed to a 24 percent reduction in the asthma mortality rate in Michigan, preventing an estimated 182 deaths. Similarly, pediatric asthma hospitalization rates in the state decreased by 28 percent between 2000 and 2009. In addition, children enrolled in Michigan Medicaid programs exhibited a 41 percent decrease in asthma hospitalizations between 2005 and 2009.