2015

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.  

The Le Bonheur Children’s Hospital’s CHAMP Program (Changing High-Risk Asthma in Memphis through Partnership) is a collaborative that serves children ages 2–18 in Memphis, Shelby County, Tennessee, who are identified as having high-risk asthma. Of CHAMP’s patients, 95 percent are African American children who suffer from poorly controlled asthma that results in preventable hospital and emergency department (ED) encounters, missed school days, and diminished quality of life.

Asthma affects up to 13.5 percent of children in Memphis, and it is the cause of 40 percent of Le Bonheur Children’s Hospital admissions. According to the 2010 Tennessee Discharge Data Set, almost 4,000 children were seen in emergency rooms in Shelby County for asthma-related problems. More than 600 of these children had multiple ED visits or hospitalizations, and nearly 200 required intensive care unit admissions. Pediatric asthma hospitalizations cost the Tennessee Medicaid system (TennCare) $2.1 million in avoidable hospitalizations, and an additional $2.6 million for ED visits.

The CHAMP Program—which is funded by the Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS)*—serves a subset of these patients, focusing on children who are most at risk for multiple or severe asthma exacerbations that would result in unplanned medical encounters, particularly those that take place in the ED or in the hospital (admission or observation). Although CHAMP patients have all been assigned a primary care physician (PCP), many lack a connection with their PCP, or do not consult the PCP for asthma episodes. They primarily live in rental properties characterized by environmental hazards—such as mold, mildew and cockroaches—that exacerbate asthma episodes, and many of them move frequently or spend significant periods of time in more than one residence over the course of a week or month.

CHAMP’s theory of change relies on an understanding that asthma care typically is not well managed as a result of several factors: the delivery system is fragmented; providers are unable to share information; and efforts to provide ongoing education, environmental improvements and social supports that will encourage self-management are unfocused. Building on that understanding, CHAMP created an Asthma Registry that includes medical encounter data from TennCare and medical data from electronic medical records. The CHAMP team comprises sub-specialist medical providers with significant experience in using the National Institute of Health’s guidelines for asthma diagnosis and management. CHAMP’s community-based staff members work to educate families and address barriers to self-management. Environmental concerns for at-risk patients are addressed through partnerships with families, schools, PCPs and programs/services. In addition a 24/7 call line is staffed by emergency medical technicians and registered nurses.

CHAMP’s various program components work in an integrated fashion to achieve its ambitious goals. CHAMP seeks to reduce asthma deaths among its target population to zero by June 15, 2015. In addition, the program aims to cut ED visits, avoidable hospitalizations and urgent care visits by 15 percent by June 30, 2015. By that same date, CHAMP also seeks to improve the quality of life for 80 percent of the patients, achieve an overall positive patient/family rating of the CHAMP program from at least 95 percent of the patients/families surveyed, and lower overall health care costs for children served by more than $4 million.

A distinguishing CHAMP feature is its Web-based asthma registry for high-risk patients, developed with the technological expertise of the University of Tennessee Health Science Center’s Division of Biomedical Informatics. The registry is a means of compiling and storing key pieces of information that pertain to the 55 data elements forming the core of the CHAMP quality metrics. The registry’s unique feature is that the TennCare administration allows the program to download an updated listing of all CHAMP patient encounters each month, including cost data. When CHAMP patients sign the institutional review board informed consent form, they allow the program to receive 1.5 years of TennCare medical-encounter data prior to enrollment and monthly updates every month after enrollment. This information furnishes an opportunity to use the registry as a case management tool, complete with warnings and automatic notifications that prompt CHAMP to contact families and provide help when, for example, prescriptions are not filled.

The most current data—covering the quarter ending December 31, 2014—show that the program’s 464 enrollees have seen significant gains in their asthma management. There was a 30-percent reduction (from baseline utilization) in the percentage of children who experienced at least one ED or urgent care visit per quarter. There was a 42-percent reduction in the percentage of children who have had at least one ED or urgent care visit for asthma in a 6-month period, and there was a 40-percent reduction in the percentage of children hospitalized each quarter for asthma-related diagnoses. With regard to possible reductions in cost of care, at the close of the 10th quarter, the average cost of care for each CHAMP patient per year was 52 percent less than it had been 1 year prior to CHAMP enrollment.  

Among CHAMP’s many accomplishments to date, the CHAMP Medical Director and Asthma Care Coordinators provided basic asthma education courses for all school nurses in the Shelby County system over a 2-year period (in 2013 and 2014). As for the environmental conditions of children with asthma and their families, CHAMP employs individual family interventions and collaboration with community partners to improve completing renovations and addressing concerns with laws, codes and community policies. Although still being refined, CHAMP shows great promise for meeting and exceeding the stated goals of its CMS-funded collaborative agreement.

*CHAMP is supported by Grant number 1C1CMS331046-01-00 from the Department of Health and Human Services, Centers for Medicare and Medicaid Services.  The contents of this document are solely the responsibility of Le Bonheur Children’s Hospital, Division of Community Health and Well Being and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.