Community in Action

In 1998, the city of Hartford, Connecticut had a growing population of low-income minority citizens with asthma. Only one-third of children with persistent asthma in this community were being treated with appropriate anti-inflammatory medication, and most of these children lived in old housing where pest infestation and overcrowding were common problems.

The community needed a cost effective asthma management program to assist busy primary care clinicians in diagnosing asthma and effectively treating patients. The result was the creation of the Easy Breathing© program.

Easy Breathing© — originally housed within the Connecticut Children’s Medical Center — focuses on five elements of care: diagnosing asthma, determining asthma severity, prescribing therapy appropriate for the asthma severity, developing a written Asthma Treatment Plan that is understood by the family, and assessing asthma control.

The program then utilizes a database to track its outcomes, including environmental exposures, interventions and feedback for clinicians. The database is also used for research and reporting purposes, and it provides clinicians with information regarding the demographics of their patient population, environmental exposures and asthma severities for all children enrolled in the program.  

An essential element of the program is the Easy Breathing© Survey, which is administered in the physician’s office when the patient comes for an office visit. The survey helps parents identify environmental exposures in the home that are potentially problematic for a child with asthma. The results of the survey are then immediately discussed with the patient and are used as a starting point for education regarding avoidance and elimination of harmful environmental conditions, such as smoking in the home.   

Today more than 106,000 children across the state have been enrolled in the Easy Breathing© program — more than 28,000 of which have asthma. This success is due in large part to extensive community partnerships between clinicians, parents, hospitals, clinics, schools, foundations, lung associations, housing authorities and pharmaceutical industry representatives that have been a cornerstone of the program from its inception.

Easy Breathing© has been tremendously successful and has lead to significant increases in the use of written treatment plans, decreases in hospitalization rates and emergency department visits for asthma, and increased usage of inhaled corticosteroids. The program is now being implemented throughout Connecticut and in nine other states.

In the early 1980s, the New York State Department of Health, Center for Environmental Health recognized that housing hazards were often complex and were best addressed by a neighborhood-level approach. As a result, the Center developed the Healthy Neighborhoods Program in 1985 — a statewide program aimed at improving housing conditions in high-risk communities through a holistic, healthy homes approach.

This program relies on an extensive network of grant-funded, local health department partners and emphasizes home environmental management as an enhancement to case management and clinical care. Local health departments initially identify target areas in the community for intervention and develop work plans to meet the specific needs of that area. These health departments are also encouraged to leverage local resources and infrastructure to ensure that the services delivered are meaningful and effective. 

During home visits, field staff members assess a wide variety of healthy homes issues, including tobacco control, fire safety, lead poisoning prevention, indoor air quality, asthma control, injury prevention and more. Following the assessment, residents are provided with products, referrals and education to help remediate any potential hazards identified during the assessment. A quarter of homes receive a three-to-six month follow-up visit to reassess conditions. Any new or ongoing problems identified during the revisit are addressed.

This program has had incredible success for residents with asthma, with marked improvements in environmental triggers, including a 14% reduction in environmental tobacco smoke exposure and improved pest control in at least 44% of homes with pest problems. There have also been significant improvements in participants’ knowledge about asthma triggers and significant decreases in the number of days with worsening asthma and in the number of work or school days missed due to asthma.

The Asthma Network of West Michigan (ANWM) is a community coalition that provides comprehensive home-based case management to 82,933 children and adults with asthma in West Michigan. ANWM has demonstrated impressive results including improved health outcomes and cost savings. This success has led to a partnership with Priority Health (a winner of the 2007 National Environmental Leadership Award in Asthma Management) who agreed to reimburse ANWM for its home visit program. This partnership with Priority Health is the nation’s first agreement between a grassroots coalition and a managed care plan. ANWM now has contracts with five local health plans and its asthma management program provides asthma education, coordination with health care providers, development of asthma action plans, home environmental assessments, and social service support. ANWM’s comprehensive care costs $2,500 per person annually and has led to a 64 percent decrease in hospitalizations and a 60 percent decrease in ER visits. These improved health outcomes resulted in approximately $800 in net health care cost savings per child per year.

Focused on inner-city children in the Flint, Michigan area, the Genesee County Asthma Network (GCAN) is a comprehensive community-based program that delivers high quality asthma care through asthma and allergy specialists, physicians, and two registered nurses who are certified asthma educators. The asthma educators complete up to 200 home assessments each year where they identify asthma triggers, while an accompanying social worker identifies potential barriers to successful asthma management such as financial hardship, transportation, or family issues. Incentives and awards motivate patients and families to follow through with self-management advice. Classroom assessments (that identify and encourage schools to fix environmental problems) often complement home inspections and ensure that patients are well prepared to address their environmental asthma triggers. Asthma educators accompany patients on clinical visits to review medications and help develop a personalized asthma action plan. With the support of Hurley Medical Center and working with numerous partners in the community— including the American Lung Association, faith-based organizations, health providers and payers, and Habitat for Humanity, which built an asthma-friendly home for one patient’s family—GCAN has produced dramatic results. Asthma-related emergency department visits have dropped by 45 percent; hospitalizations by 25 percent.

Serving nearly 38 million people, the California Department of Public Health - Center for Chronic Disease Prevention and Health Promotion provides multi-faceted asthma management and care to children and adults through programs based in schools, workplaces, and the community at large. The Work-Related Asthma Prevention Program provides customized educational materials to underserved adults with workplace-related asthma, analyzes data to identify high-risk industries and appropriate interventions, and conducts site investigations. The California Breathing Program conducts school-based programs that emphasize environmental interventions, train staff and childcare providers, and offer incentive-based awards to schools that create healthy environments. Community-based grants to local organizations fund a range of interventions including technical assistance on topics such as pest management in housing developments, second-hand smoke reduction, and mold intrusion training for code enforcers. Environmental interventions are complemented by the California Asthma Public Health Initiative where clinicians assess individual allergen sensitivities, educate families, and often provide free products to reduce exposure to triggers. In participating clinics, the number of children with written asthma action plans increased 84 percent, and asthma-related emergency department visits dropped by 78 percent.

Based on the premise that strong patient-provider interaction is key to asthma management, the Bethlehem Partnership for a Healthy Community identifies and educates high-risk children and their families through the school system, improves access to preventive services and care, and provides up-to-date asthma education to the medical community. In partnership with St. Luke’s Hospital and the Bethlehem Area School District, the initiative helps to manage asthma through multiple access points: school-based health clinics, Open Airways Programs, mobile school health clinics, and St. Luke’s Hospital Clinic. The program educates and supports clinical care teams by providing annual education and training to health care providers and coalition partners. Patient education includes multiple, bilingual home visits and thorough patient follow-up. Working with the Bethlehem Health Bureau, the initiative evaluates homes for environmental triggers while distributing trigger-reducing items (such as mattress covers and green cleaning supplies), provides one-on-one education to families, and assists tenants in contacting landlords in order to correct mold and cockroach issues. Through a successful partnership with Lehigh University, the program expanded to address outdoor air quality during the home visit survey. The initiative has proven to be effective: From 2007-2008, multiple asthma-related pediatric emergency department visits for individual patients decreased by 56 percent.

In 2005, a local hospital and community partners applied the principles of community- based participatory research to develop the Washington Heights Inwood Network (WIN) for Asthma. This comprehensive program is designed to facilitate effective and sustainable asthma management in Northern Manhattan, a community with childhood asthma rates that are four times the national average. WIN is a multi-level, community-driven program that enhances case identification and follow-up for children. Through collaboration with key partners, including local day care centers, schools, clinics and community-based organizations, WIN provides community-wide asthma screening and education. Once families are enrolled in the program, bilingual community health workers offer family-focused asthma education, address household triggers, and link families to the clinical and social resources needed to facilitate effective and sustainable asthma management. By engaging and supporting local providers through the delivery of the evidence-based intervention, Physician Asthma Care Education (PACE), WIN works to ensure providers adhere to the latest asthma guidelines, resulting in improved quality of care. Through a partnership with the National Initiative for Children’s Healthcare Quality, WIN developed a comprehensive protocol for post-PACE provider support involving practice-based support. Through collaboration with multiple hospital divisions, the launch of a grassroots marketing campaign, and the development of a long-term business plan, WIN has worked to increase its visibility and successfully sustain its program. WIN’s program success is demonstrated in data collected from Community Health Workers (CHWs): Over a 3-year period, the number of asthma related emergency department visits and hospitalizations decreased by more than 50 percent; caregivers’ confidence in controlling their children’s asthma increased by 40 percent; and asthma-related school absenteeism decreased by 30 percent.

Since 2000, the Sinai Urban Health Institute (SUHI) and Sinai Children’s Hospital (SCH) have partnered to reduce the burden of asthma on vulnerable Chicago communities. As many as one in four children living in the communities served by the Sinai Health System suffer from asthma, as revealed by the Sinai Improving Community Health Survey. Recognizing the disproportionate asthma burden faced by these communities, a series of four comprehensive asthma interventions have been conducted over the past 10 years. Each of these initiatives has focused on decreasing asthma-related morbidity and improving participants’ quality of life by utilizing Community Health Workers (CHW)— members of the community trained to deliver case-specific asthma education through home visits. With funding from the U.S. Centers for Disease Control and Prevention, SUHI and SCH initiated a comprehensive, multifaceted program in September 2008, called Healthy Home, Healthy Child: The Westside Children’s Asthma Partnership (HHHC). This unique program draws from the strengths of its collaborations with partner organizations and community members to address medical, social and environmental factors of asthma. At the heart of this program is the CHW, who provides one-on-one asthma education and environmental trigger reduction counseling to families in their homes. The CHWs also serve as a liaison between the family and medical system. Cost savings analyses and evaluations of these programs have enabled SUHI to demonstrate the approach’s value, proving that the program was a wise investment. Since the inception of the SUHI Pediatric Asthma Programs, there has been on average a 50 percent reduction in frequency of symptoms experienced by children (50.4 percent – 63.6 percent) and significant declines in asthma-related emergency department visits (47.6 percent – 73.5 percent) and hospitalizations (50.0 percent – 81.0 percent). In addition, the SUHI Pediatric Asthma Model has been replicated in other areas around Illinois.