Be Visible: Funders Support What They Know
At the beginning of the 2005-2009 MCAN grant, WIN's founders explored where within the NewYork Presbyterian Hospital system to house the program. Early on, they recognized that positioning WIN under the Director of Community Health Outreach and Marketing in the Ambulatory Care Network would allow the program to develop within an established framework for hospital-community programming and provide a mechanism for partnering with ambulatory clinics that serve many local children with asthma. Under these auspices, WIN established itself as the hospital's "asthma program" and collaborated with multiple hospital divisions, increasing the program's visibility.
During the last year of MCAN funding, WIN convened a multi-disciplinary group to develop a Business Plan for WIN to document the program's return on investment and cost savings associated with reduced healthcare utilization. This effort contributed to WIN's sustainability by spotlighting the program's health outcomes. This resulted in the unintended benefit of recruiting program champions from the high-level Business Plan team, including Community Health and Finance Departments and from the Office of Strategy. The hospital recently decided to contribute to the financial support of WIN.
The WIN for Asthma program reduces the burden of asthma in a low-income, culturally diverse, urban community, where pediatric asthma rates are high--childhood asthma rates are four times the national average--access to care is fragmented and a range of obstacles to effective asthma control makes pediatric asthma a major public health problem. In 2005, Merck Childhood Asthma Network - MCAN - gave researchers a four-year grant to address pediatric asthma disparities through WIN, a hospital-community partnership to strengthen the community's existing network of care in order to improve outcomes for children with poorly controlled asthma. WIN's goal is to reduce severe asthma exacerbations, to decrease asthma-related emergency department (ED) visits, hospitalizations and school absenteeism.
Conduct Needs-Based Planning--Seek Input from the Community
Community ownership and integration has been built into WIN's program design from the start. When they received the MCAN grant, the researchers who initiated WIN convened a network of community stakeholders committed to filling gaps in the local system of asthma care. The research team and representatives from four community-based organizations--Alianza Dominicana, Inc., Northern Manhattan Improvement Corporation, Fort George Community Enrichment Center and Community League of the Heights--joined together to design WIN. They applied the principles of community-based participatory research and spent the first nine months setting program strategy, recruiting and training staff from the community, developing asthma care guidelines and protocols, creating evaluation tools and forming the WIN Leadership Task Force. The Task Force, which includes stakeholders from the community, Columbia University and the hospital, oversees and supports WIN programming.
Ensure Mission-Program Alignment
To ensure it stays focused on asthma disparities, WIN works hard to find and treat at-risk children by conducting screening for uncontrolled asthma in daycare facilities, schools, clinics and other community organizations. In addition, all children admitted to the Morgan Stanley Children's Hospital of New York with a diagnosis of asthma are automatically referred to WIN. Through its broad network of collaborators, WIN is able to assess a large pediatric population. Families of children who meet the risk criteria are offered WIN's intensive year-long care coordination service.
WIN's target population is multi-lingual, culturally diverse, has low levels of health literacy and high levels of poverty and faces multiple obstacles that often prevent effective asthma care. To make it easy for families to support effective asthma care for their children, WIN's care model uses bilingual community health workers (CHWs) located in organizations across the community. The CHWs serve as the single point of contact for families to facilitate culturally-appropriate and comprehensive asthma education, home environmental assessments, support for setting individualized asthma control goals, referrals for clinical and social services and ongoing support. The CHWs, who are linked to the hospital and the community, facilitate communication with clinicians, provide broad-spectrum support to families and strengthen ties between the health care system and the community.
STRONG COMMUNITY TIES--MAKE IT EASY TO ACCEPT SERVICES
Many caregivers in the community face serious obstacles that prevent them from appropriately caring for their child's asthma. Through WIN, all families receive referrals for support services, including immigration, domestic violence, employment, housing, mental health, smoking cessation, tenants rights, housing assistance and others. A secondary benefit is that the referrals further link families to the community by connecting them to local resources. WIN leaders believe that a good deal of the program's success is attributable to helping families address life's obstacles as well as their child's asthma.
INTEGRATED HEALTH CARE SERVICES--EDUCATE AND SUPPORT CLINICAL CARE TEAMS
To strengthen the local network of care, a provider outreach team engages and supports providers in Physician Asthma Care Education (PACE) and QI initiatives. PACE reaches the majority of pediatric providers in WIN's community with trainings on the clinical aspects of asthma, medication management and introduction and reinforcement of the EPR-3 and communication skills to address asthma during patient encounters. PACE also covers the importance of asthma action plans and how to educate parents on their use. In partnership with the National Initiative for Children's Healthcare Quality, WIN developed a QI protocol for post-PACE provider support. Providers receive one-on-one training in their practice on QI projects for asthma. A WIN provider liaison helps providers establish projects and track their improvements over time. This led to widespread implementation of the EPR-3 through projects initiated by the providers themselves.
Evaluate Program Implementation and Program Impact
WIN seeks to reduce severe pediatric asthma exacerbations and related healthcare utilization through intensive care management and improvements in the quality of clinical asthma care. WIN evaluates its efforts and their impact through process measures to assess implementation of the care management program, including: the percent of families who accept home visits; the percent of those who take steps to make their homes asthma-friendly; and the number of community providers who receive education and engage in WIN's quality improvement (QI) initiatives. WIN also assesses the program's outcomes through a survey of caregivers with children enrolled in the care management program.
WIN conducts caregiver interviews during enrollment in the care management program and again at 6 and 12 months. Descriptive statistics assess the impact of the intervention on caregiver self-efficacy and key asthma morbidity indicators. Over a three-year period, CHWs enrolled 360 families. After 12 months in the program, caregiver confidence in their ability to control their child's asthma increased by 40%, ED and hospitalization visit rates decreased by more than 50% and child school absenteeism decreased by 30%. In addition, WIN engaged 306 providers based in Washington Heights/Inwood and Harlem in an asthma care education program and 60 local pediatric providers in an asthma care QI initiative. The education program reached the vast majority of community pediatric providers and enhanced the delivery of National Guidelines for the Diagnosis and Management of Asthma (EPR-3) throughout the community.