Community in Action

Housed within the Rhode Island Department of Health, the mission of the Rhode Island Asthma Control Program (RIACP) is to reduce the overall asthma burden and asthma health disparities in the state. The program provides community-based services and interventions for children 17 years and younger with asthma in four high-poverty, urban “core cities” throughout the state, where the burden of asthma is the highest. The burden of asthma also falls disproportionately on black and Hispanic children, children in low-income households, and children living in low-income urban neighborhoods. These children are not only at high risk of developing asthma but also are at risk of having more severe asthma once the disease develops. Among children living in the core cities, the rate of primary asthma hospitalizations was twice as high compared with the rest of the state.

RIACP is well-known for its long-term partnerships with researchers and hospitals, as well as public health, housing, social justice and environmental organizations across the state, including Hasbro Children’s Hospital, St. Joseph Health Center, the Asthma Regional Council of New England, UnitedHealthcare®, and the Green and Healthy Homes Initiative. Additionally, RIACP’s efforts are focused around a collaborative approach with linkages between healthy housing, the health care sector, and other regional collaborations. RIACP’s work to reduce the asthma burden in Rhode Island is critical for developing, evaluating and sustaining the program’s strategies to expand the reach of its comprehensive asthma services. RIACP was recognized by the Centers for Disease Control and Prevention (CDC) for its reimbursement efforts and participated in the CDC’s 6|18 Initiative. Through this national leadership program, RIACP received CDC technical assistance and Medicaid support to develop a business case for the reimbursement of RIACP’s asthma home-visiting initiative, the Home Asthma Response Program (HARP).

HARP is an evidence-based program established in 2010 to address the needs of children with poorly controlled asthma and uses certified asthma educators (AE-Cs) and community health workers (CHWs) to conduct up to three intensive in-home sessions for each child. During these home visits, AE-Cs and CHWs provide tailored educational and environmental services, including an extensive environmental assessment, asthma self-management education, and cost-effective supplies to reduce home asthma triggers. CHWs have reported reductions in environmental triggers, including mold, pests, dust, pets, tobacco smoke and chemicals. In addition, using hospital claims data, the program was able to show a 75% reduction in asthma-related hospital and emergency department costs for HARP participants. For every $1 invested, HARP participants realized a $1.33 return on investment. The program recently expanded to provide HARP home-visiting services statewide for Medicaid-enrolled children.

In 2015, RIACP and partners launched the Comprehensive Integrated Asthma Care System (CIACS) to link home-based, school-based and health systems interventions as one unified package. HARP became one of four interventions offered, in addition to the Breathe Easy at Home Project, Controlling Asthma in Schools Effectively Project, and Draw A Breath workshop program. These interventions have been implemented in the four core cities, and a CIACS Advisory Group—comprising public health professionals, asthma researchers, a nurse, CHWs, and a data manager—works collaboratively on the implementation and evaluation of asthma services. The CIACS Advisory Group is Rhode Island’s first researcher-practitioner partnership to reduce the burden of asthma in children.

RIACP has been successful in serving children with poorly controlled asthma and reducing these children’s likelihood of repeated asthma emergency department visits and inpatient hospitalizations. RIACP also has also built partnerships with local, statewide, regional and national partners to reduce individual- and neighborhood-level disparities in pediatric asthma.

Omaha Healthy Kids Alliance (OHKA) is a children’s environmental health organization dedicated to improving children’s health through fostering healthy homes. OHKA developed the Asthma In-Home Response (Project AIR) program to serve children ages 18 and younger who have an asthma or asthma-related diagnosis.

Project AIR’s mission is to help reduce in-home hazards for children with asthma in the Omaha metropolitan area. By reducing in-home hazards, AIR works to improve the quality of life for children with asthma and their families by educating them on indoor environmental asthma triggers, empowering positive behavior changes, connecting them with low-cost supportive solutions, and supporting them by providing free construction services. Project AIR aims to reduce emergency department visits and hospitalizations resulting from pediatric asthma, decrease symptomatic days, improve quality of life for children and their families, and increase productivity by reducing asthma-related missed school and work days.

OHKA serves a population that is disproportionately affected by specific health outcomes and faces additional socioeconomic barriers that often take precedence over the intended Project AIR intervention. Most families in Project AIR tend to identify as Black/African American, with the second most frequent racial self-identification being Latino/Hispanic and the third most frequent group being Caucasian. The average household income of Project AIR clients is about $26,000, and the average age of houses that Project AIR families live in is 75 years old. OHKA has a wide network of community partners that assist families with challenges not directly related to their health. Assistance includes help with landlord-tenant disputes, rental assistance, job placement and food pantries. OHKA’s work is successful because of the collaborations and partnerships that have been established to assist in reducing barriers for families enrolled in Project AIR so that they are able to focus on health-related interventions.

OHKA’s Project AIR leverages key partnerships with WellCare of Nebraska (part of the managed care organization, WellCare® Health Plans, Inc.), Children’s Hospital & Medical Center (Omaha), and Boys Town National Research Hospital’s Allergy, Asthma, Immunology and Pediatric Pulmonary Clinics. In addition to formal partnerships, Project AIR provides an assigned asthma case manager, and in-home visits are performed by two OHKA staff who are trained in environmental management and asthma education. After the initial visit, each family receives a Healthy Home Report that is developed by the visiting team. This report includes a description of the home, identified home hazards, low-cost solutions, results of environmental testing and construction, and scopes of work. This document can be shared with physicians, if requested and approved by the family. In addition to a customized environmental supply kit, families often are referred to community organizations for legal and employment services or food pantry access.

Project AIR evaluates the program performance outcomes under four criteria: severity of asthma, quality of life, environmental health of the home, and behavioral changes. To assess how and where the program can be improved, Project AIR also examines internal measures, such as cost per intervention, cost of supplies, follow-up rate and dual-enrollment rate. After 12 months, Project AIR noted a significant decrease in symptomatic days, fewer missed school days, fewer emergency room visits and hospitalization rates, and a decrease in medication usage. Additionally, an evaluation of Project AIR return on investment showed for every $1 invested in a family and their home, a $1.83 return was made.

Project AIR integrates a collaborative approach to asthma intervention and diverse funding sources to create positive change in the Omaha metropolitan area. The program’s success has introduced new partnerships and improved outcomes throughout the asthma community.

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.

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. 

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.

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)

The Green & Healthy Homes Initiative (GHHI) serves low-income families living in Baltimore City, Maryland, using a transformative asthma management model that combines in-home family asthma education; a comprehensive health, safety and home energy audit; and root cause remediation.

Residents of Baltimore City, Maryland, face a higher than average rate of asthma prevalence, hospitalizations, emergency visits and deaths compared with residents of other Maryland regions and the nation as a whole. Approximately 18.6 percent of Baltimore City children have asthma, compared with the national average of only 5 to 8 percent. Furthermore, African Americans living in Baltimore are disproportionately affected. African Americans with asthma visit the emergency room 6.5 times more often than Caucasians. The asthma hospitalization rate for children in Baltimore City is twice the rate of Maryland as a whole, and African Americans in Baltimore experience an asthma mortality rate that is     3 times higher than that of Caucasians.

Working as a coalition of 35 federal, state, local, nonprofit, university and philanthropic partners, GHHI provides health-based housing intervention services to families with asthmatic children ages 2–14 who live in neighborhoods with the highest rates of asthma in the state. Homes in these very low-income communities usually are in deteriorating condition, with such environmental health hazards as high levels of dust, pest antigens, mold and very poor indoor air quality. Following the recommendations of an Environmental Assessment Technician’s report, GHHI deploys professional hazard reduction crews to remediate these home-based environmental hazards to reduce and eliminate avoidable asthmatic episodes.

GHHI began in Baltimore, Maryland, as the Coalition to End Childhood Lead Poisoning. Although originally focused on reducing lead hazards, the organization’s community-based workers perceived that other home-based environmental health hazards—especially asthma triggers—also demanded attention to support children’s health. In 2000, with seed money from the Annie E. Casey Foundation, the Coalition established one of the first Healthy Homes programs in the nation. In 2013, the Coalition changed its name to GHHI to reflect its broadened scope of services and mission impact, with Baltimore as its flagship site.

Since 2000, GHHI Baltimore has conducted housing interventions in 1,118 homes of patients diagnosed with asthma in Baltimore City. By remediating home-based environmental asthma triggers, GHHI has effectively reduced the incidence of asthma among those patients and stopped avoidable visits to the Emergency Department (ED) and hospital. GHHI’s highly successful approach served as the model for Baltimore City’s Office of Green, Healthy and Sustainable Housing. Unlike other Healthy Homes programs, GHHI integrates “green” weatherization and energy efficiency work with traditional healthy homes services, such as integrated pest management and mold removal, to achieve maximum health benefits for the target population. Moreover, GHHI Baltimore builds the community’s human capital. GHHI does this by deploying its own team of contractors to conduct multi-component home interventions and by hiring residents of at-risk Baltimore communities who receive training and accreditation to conduct interventions.

The Maryland Department of Health and Mental Hygiene’s (MDHMH) most recent data showed that, in 2009, 5,514 children in Baltimore City went to the ED for asthma, of whom 792 children who were hospitalized. Data also indicate that 52 percent of children in Baltimore who are hospitalized with asthma are residents of GHHI Baltimore’s target communities. If 52 percent of the city’s 5,514 children with asthma ED visits reside in GHHI’s target communities, GHHI Baltimore reaches approximately 4–7 percent of all children with persistent to severe asthma in those communities. To serve these children, GHHI has an intake stream from established referral sources and long-term partners, including managed care organizations (MCOs) and asthma clinics. GHHI annually serves 100–200 children diagnosed with asthma.  

GHHI’s integrated, community-based approach involves all of the necessary partners to provide comprehensive care.  With MDHMH funding, GHHI provides training to clinicians and staff of local community clinics and participates in Grand Rounds Trainings for physicians, pediatricians, nurses and other health care providers. GHHI reaches approximately 100 health care providers annually through the Initiative’s instruction on integrating home-based and environmental-focused intervention with comprehensive clinical care. When patients enter the program, an environmental assessment and education team meets with the family to review their home conditions. A GHHI Environmental Asthma Educator serves as the primary point of contact among the family and provider/nurse care manager/case management. The Environmental Asthma Educators staff review the patient’s Asthma Action Plan and medication management. The home asthma educators reinforce the information provided by the clinician and ensure that any behavior that may impact asthma, such as smoking, is addressed.

Besides serving clients directly, in the last 7 years, GHHI has conducted 1,743 outreach presentations and events, including 168 school presentations, 154 daycare center events, 742 community center events and 70 MCO presentations, providing more than 121,912 Baltimore City residents with information about healthy homes and asthma prevention.  

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.