Promote Institutional Change for Sustainability
CDC seeded the HHHC with $1.5 million, but the partnership has continually sought funding for sustainability from grants, foundations and the community. Everyone involved in the HHHC has discussed the imperative to sustain the program once start-up funding is exhausted. The CAB discusses how to sustain the program by making effective asthma self-management and environmental controls top priorities for all community-based leaders. HHCC leaders have continually discussed sustainability with the project staff. Also, key partners in program delivery, such as the MTO, HDA and CAC, have focused on ways to sustain their contributions to the program from within their organizations. These partners are well-established programs whose mission is to assist low-income families to create healthy homes and healthy lives, therefore, the HHHC program is a good fit for them. The partners' contributions to the HHHC are likely to be incorporated as line items in their long-term budgets, because HHHC offers an evidence-based solution for demonstrably achieving partner organizations' goals.
Since 2000, SUHI and Sinai Children's Hospital (SCH) have worked to reduce the burden of asthma in underserved, minority Chicago communities, where up to one in four children suffer from asthma. In 2008, with funding from the Centers for Disease Control and Prevention (CDC), SUHI and SCH initiated Healthy Home, Healthy Child: The Westside Children's Asthma Partnership (HHHC), a comprehensive, community-based program that centers on an intensive, home visit program led by community health workers (CHWs) to address asthma medically, socially and environmentally.
COMMITTED LEADERS AND CHAMPIONS-- CREATE PROGRAM CHAMPIONS
The HHHC project is fortunate to have a champion in the Chief Executive Officer of the Sinai Health System, Alan Channing. He supports the program's efforts, proclaiming its accolades within the hospital and the community. He has led efforts to integrate the program into the hospital's system by building relationships with the SCH, the ED and the Pharmacy Department. In the community, the program is championed by the CAB.
Let Data Guide the Program Planning, Design and Implementation
SUHI and SCH targeted their work in the Westside area, because they had strong data indicating the community's considerable need for improved asthma care. In 2003, SUHI worked with community organizations in Chicago to design and conduct the largest door-to-door health survey in the city's history. Findings indicated high rates of poorly controlled asthma in North Lawndale, a neighborhood in the heart of Chicago's Westside where Sinai Health System also is located. The survey revealed that 23% of children in the area had a diagnosis or symptoms of asthma; 80% of children with an asthma diagnosis were not receiving appropriate medications; and nearly half were exposed to tobacco smoke on a daily basis. In addition, the pediatric asthma hospitalization rate in North Lawndale from 2004 to 2006 was 150% higher than the rate in the rest of Chicago. The data influenced the design of asthma interventions, particularly the selection of the CHW-led home visit model. This model brings culturally sensitive care to the community to ensure a strong connection to the health care system and provide interventions in the environments where children spend the majority of their time.
Beginning in 2000, SCH and SUHI began partnering on a pediatric asthma initiative to reduce the impact of asthma through case management and one-on-one asthma education delivered in a clinic and by telephone. The next stage of program development focused on reducing asthma-related morbidity and improving quality of life (QoL) by utilizing CHWs delivery of case-specific asthma education through home visits. The third iteration of the program incorporated SUHI/SCH's successful CHW-led home-visit model into a larger, statewide initiative led by the Illinois Department of Public Health to improve pediatric asthma outcomes.
SUHI's and SCH's research conducted on the three prior initiatives yielded significant reductions in asthma-related health care utilization. This culminated in the development of the most comprehensive initiative to date: the HHHC. The HHHC exclusively focuses on children with poorly controlled asthma living in poor communities on the Westside. The program's objective is to significantly impact asthma-related measures of morbidity, urgent health care utilization and QoL by decreasing asthma triggers in the home environment, improving asthma care knowledge among primary caregivers and improving caregivers' confidence in their ability to manage asthma. To achieve these goals, CHWs provide asthma education during six home visits over the course of a year. Visits focus on providing tailored education to caregivers and children on medical management and addressing the disproportionate presence of asthma triggers in the home. Having CHWs visit participants' homes means that families do not have to arrange for transportation as visits can be scheduled to accommodate families. The CHWs can serve as advocates and liaisons between the families and the broad network of partners that SCH and SUHI have assembled to support the HHHC. The CHWs also record case information in a shared database for partners to access and initiate extensive telephone and email communication to discuss cases, asthma management education, home environmental exposures and controls, needed social support and assistance families need to navigate the health care system.
Conduct Needs-Based Planning: Seek Input from the Community
CAB helps to ensures that HHHC receives vital insight into its community. The CAB guides the asthma outreach and home intervention process and helps the program reach as many children as possible by educating the community about the program and how to access it. CAB members include parents and caregivers of children with asthma, leaders of community-based organizations, representatives from faith-based groups, business owners and other stakeholders. The CAB engages the community, guides the program's design and helps to foster sustained asthma care improvements.
STRONG COMMUNITY TIES--ENGAGE YOUR COMMUNITY 'WHERE IT LIVES'
The HHHC is carried out by CHWs, who have been recruited from the local community and have a personal connection to asthma. After their training, CHWs make home visits to provide comprehensive asthma education, trigger assessment and reduction and referrals for social and legal support. CHWs also serve as liaisons to the medical system, encouraging visits with primary care providers (PCPs), providing referrals for those without a PCP and working with PCPs to develop asthma action plans. The HHHC program reaches beyond enrolled families through community-wide education, such as presentations to clinics, residents, nurses and other health care professionals and asthma basics workshops for schools, day care centers, parent groups and others.
SUHI developed the Sinai Asthma Education Training Institute (SAETI) to train providers in the proper management of asthma in accordance with the National Guidelines for the Diagnosis and Management of Asthma (EPR-3). The SAETI trains CHWs, as well as nurses, respiratory therapists, medical residents and others. To date, SUHI has trained nearly 100 CHWs and other medical staff in Illinois. For the HHHC, CHWs receive additional training from the MTO on conducting environmental assessments and addressing triggers in the most effective yet practical manner. HHHC CHWs also receive training on problem solving and motivating clients to develop self-management skills. After formal training, new CHWs shadow experienced CHWs for approximately one month before beginning their one-on-one work with families.
Use Evaluation Data to Demonstrate the Business Case
QoL improvements and reduced morbidity are the ultimate goals of the HHHC program, but program leaders also hope to demonstrate a tangible return on investment (ROI). Data on time spent by CHWs and partner organizations currently is being collected as are related health care utilization data for participants, so that SCH and SUHI can calculate the ROI from the HHHC. Rigorous cost-benefit analyses conducted on the preceding initiatives showed impressive results. The partnership's first asthma initiative generated $13.29 savings for every dollar spent and the second initiative generated $5.58 savings for every dollar spent. SCH and SUHI leaders share the cost-savings data internally and externally to inform the public and their partners of the program's successes.