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Low-income adults with uncontrolled asthma saw both their asthma control and quality of life improve with the help of an in-home, self-management asthma support program delivered by community health workers (CHWs), according to a report published online by JAMA Internal Medicine.

Asthma affects 24.6 million American, including 17.5 million adults. Control of asthma is inadequate despite the availability of effective methods to manage it. Home-based self-management support to improve asthma control among children is well established. However, the effectiveness of home visits for adults has not been well studied.

James Krieger, M.D., M.P.H., of Public Health-Seattle and King County, Washington, and co-authors report on the Home-Based Asthma Support and Education trial (HomeBASE). The study enrolled 366 participants with uncontrolled asthma: 189 to usual care and 177 to the intervention, which included CHWs who provided education, support and service coordination during home visits. The CHWs provided an average of 4.9 home visits during a one-year period.

The intervention group had greater increases in the average number of symptom-free days over two weeks (2.02 days per two weeks more) and quality of life as measured on a questionnaire increased an average of 0.50 points. However, average urgent health care use episodes in the past 12 months decreased similarly in both groups from an average of 3.46 to 1.99 episodes in the intervention group and from an average of 3.30 to 1.96 episodes in the usual care group.

“We anticipate that this intervention could be readily replicated by health organizations serving diverse, low-income clients, suggesting that it could reduce asthma-related health inequities. Intervention protocols can be implemented without specialized training or resources. The cost per participant was approximately $1,300 (2013 U.S. dollars), substantially less than one year’s supply of an inhaled corticosteroid,” the study concludes.

Sponsoring Programs:

Healthy Homes, U.S. Department of Housing and Urban Development

State Tobacco Education and Prevention Partnership, Colorado Department of Public Health and Environment

This document provides codes used to bill Medicaid within states for asthma care services, including descriptions of services covered. The information can be used to advocate for expanded Medicaid and private payer reimbursement in your state.

With more states exploring reimbursement for asthma interventions – for home-based asthma education, home assessments, and/or products that support environmental management of asthma triggers – this document will be updated frequently to reflect new policy changes.

Community health workers (CHWs) have shown, time and again, that they can improve health outcomes while reducing healthcare costs. Reductions in chronic illness, improved medication adherence, more patient involvement, and better community health have been accompanied by a return on investment of more than $2 for every dollar invested.

One approach states have explored to counteract these barriers is to develop some sort of CHW credentialing system. The goals of credentialing, as described by Carl Rush in 2012, are to achieve greater respect for CHWs among other healthcare professions, improved financial compensation and working conditions, increased job stability, and opportunities for more sustainable funding. The connection between insurance reimbursement and credentialing or standardized training is particularly significant, as both public and private insurance plans are likely to require some form of credentialing in order to pay for CHW services. At the same time, many CHWs are concerned that credentialing will create barriers to entry for the individuals best suited to the job (i.e., members of low-income communities who may not speak English as a first language), and/or take CHWs away from their community connections by focusing on credentialed ―skills‖ over community relationships.

This report by Harvard Law School's Center for Health Law & Policy Innovation is designed to review some of the major policies in different states and highlight some of the issues that arise in these programs. There is no single right approach. With sufficient stakeholder engagement, each state can develop policies tailored for its community.