Children’s Hospital Boston’s Community Asthma Initiative (CAI): An Innovative Community-based Intervention Leading to Policy Changes Elizabeth R. Woods, MD, MPH, Urmi Bhaumik, MBBS, MS, DSc, Susan J. Sommer, MSN, RNC Amy B. Burack, RN, MA, AE-C, Lauren K. Ebe, BA Alaina J. Kessler, BS, BA Lisa M. Mannix, BA Elizabeth M. Klements, MS, APRN, BC, Shari Nethersole, MD Elizabeth R. Woods, MD, MPH, Urmi Bhaumik, MBBS, MS, DSc, Susan J. Sommer, MSN, RNC Amy B. Burack, RN, MA, AE-C, Lauren K. Ebe, BA Alaina J. Kessler, BS, BA Lisa M. Mannix, BA Elizabeth M. Klements, MS, APRN, BC, Shari Nethersole, MD

Funding in Part From BANK OF AMERICA BANK OF AMERICA Anonymous Individual Donor Anonymous Individual Donor Healthy Tomorrows, HRSA grant #H17MC06705 Healthy Tomorrows, HRSA grant #H17MC06705 CDC REACH U.S. #1U58DP CDC REACH U.S. #1U58DP Office of Child Advocacy Office of Child Advocacy Children’s Hospital Boston’s Program for Patient Safety and Quality Children’s Hospital Boston’s Program for Patient Safety and Quality BANK OF AMERICA BANK OF AMERICA Anonymous Individual Donor Anonymous Individual Donor Healthy Tomorrows, HRSA grant #H17MC06705 Healthy Tomorrows, HRSA grant #H17MC06705 CDC REACH U.S. #1U58DP CDC REACH U.S. #1U58DP Office of Child Advocacy Office of Child Advocacy Children’s Hospital Boston’s Program for Patient Safety and Quality Children’s Hospital Boston’s Program for Patient Safety and Quality

Asthma Hospitalization Rates in Boston Leading cause of hospitalization at Children’s Hospital Boston Leading cause of hospitalization at Children’s Hospital Boston 70% of children hospitalized for asthma at CHB come from Roxbury, Dorchester, Jamaica Plain, Roslindale and Hyde Park 70% of children hospitalized for asthma at CHB come from Roxbury, Dorchester, Jamaica Plain, Roslindale and Hyde Park Rate of asthma hospitalizations for children in Boston in 2003 increased 25% from the previous year Rate of asthma hospitalizations for children in Boston in 2003 increased 25% from the previous year (Health of Boston 2005, BPHC, (Health of Boston 2005, BPHC, Leading cause of hospitalization at Children’s Hospital Boston Leading cause of hospitalization at Children’s Hospital Boston 70% of children hospitalized for asthma at CHB come from Roxbury, Dorchester, Jamaica Plain, Roslindale and Hyde Park 70% of children hospitalized for asthma at CHB come from Roxbury, Dorchester, Jamaica Plain, Roslindale and Hyde Park Rate of asthma hospitalizations for children in Boston in 2003 increased 25% from the previous year Rate of asthma hospitalizations for children in Boston in 2003 increased 25% from the previous year (Health of Boston 2005, BPHC, (Health of Boston 2005, BPHC,

Race/ethnic Disparities Asthma hospitalization rates for Latino and Black children in 2003 were 5 times the rate for white children (Health of Boston, 2005) Asthma hospitalization rates for Latino and Black children in 2003 were 5 times the rate for white children (Health of Boston, 2005) Of CHB asthma admissions (1/04-6/04) 23% were Black/African American, and 20% Hispanic, whereas of total CHB patients 11% were Black/African American and 13% were Hispanic Of CHB asthma admissions (1/04-6/04) 23% were Black/African American, and 20% Hispanic, whereas of total CHB patients 11% were Black/African American and 13% were Hispanic Asthma hospitalization rates for Latino and Black children in 2003 were 5 times the rate for white children (Health of Boston, 2005) Asthma hospitalization rates for Latino and Black children in 2003 were 5 times the rate for white children (Health of Boston, 2005) Of CHB asthma admissions (1/04-6/04) 23% were Black/African American, and 20% Hispanic, whereas of total CHB patients 11% were Black/African American and 13% were Hispanic Of CHB asthma admissions (1/04-6/04) 23% were Black/African American, and 20% Hispanic, whereas of total CHB patients 11% were Black/African American and 13% were Hispanic

School prevalence Average prevalence of asthma in the Boston Public Schools was 16% in school year Average prevalence of asthma in the Boston Public Schools was 16% in school year 5 Boston Schools reported prevalence rates >24%, highest at 39% 5 Boston Schools reported prevalence rates >24%, highest at 39% Average prevalence of asthma in the Boston Public Schools was 16% in school year Average prevalence of asthma in the Boston Public Schools was 16% in school year 5 Boston Schools reported prevalence rates >24%, highest at 39% 5 Boston Schools reported prevalence rates >24%, highest at 39%

Children’s Hospital Boston Community Asthma Initiative

The Program Model Nurse case management, individualized asthma plan Nurse case management, individualized asthma plan -Asthma education, medication management -Connection to PCP, Allergy evaluation, insurance, housing, community resources Boston Asthma Initiative (BAI) and nurse home visits, environmental assessment, asthma teaching, assistance with environmental triggers Boston Asthma Initiative (BAI) and nurse home visits, environmental assessment, asthma teaching, assistance with environmental triggers Integrated Pest Management Integrated Pest Management Linkage with community agencies, activities, and schools Linkage with community agencies, activities, and schools Nurse case management, individualized asthma plan Nurse case management, individualized asthma plan -Asthma education, medication management -Connection to PCP, Allergy evaluation, insurance, housing, community resources Boston Asthma Initiative (BAI) and nurse home visits, environmental assessment, asthma teaching, assistance with environmental triggers Boston Asthma Initiative (BAI) and nurse home visits, environmental assessment, asthma teaching, assistance with environmental triggers Integrated Pest Management Integrated Pest Management Linkage with community agencies, activities, and schools Linkage with community agencies, activities, and schools

Access to Care, Connection to Primary Care, Medication Management, Asthma Action Plan

Homesafe Kit: Boston Public Health Commission Plastic trash can/cleaning supplies Plastic trash can/cleaning supplies Plastic food containers Plastic food containers Foam/Copper gauze Foam/Copper gauze Non-toxic insect traps Non-toxic insect traps Mouse (sticky) traps Mouse (sticky) traps Weather stripping Weather stripping Bedding encasements Bedding encasements Bilingual information cards Bilingual information cards Plastic trash can/cleaning supplies Plastic trash can/cleaning supplies Plastic food containers Plastic food containers Foam/Copper gauze Foam/Copper gauze Non-toxic insect traps Non-toxic insect traps Mouse (sticky) traps Mouse (sticky) traps Weather stripping Weather stripping Bedding encasements Bedding encasements Bilingual information cards Bilingual information cards

Additional Collaboration: Boston Inspectional Services Breathe Easy Program

Asthma Health Project/ BPHC: Combines physical activity with asthma education to improve health and well being of Boston children living with asthma Boston Asthma Games Boston Asthma Games Boston Asthma Swim Boston Asthma Swim Boston Asthma Summer Program Boston Asthma Summer Program Boston Asthma Games Boston Asthma Games Boston Asthma Swim Boston Asthma Swim Boston Asthma Summer Program Boston Asthma Summer Program

Boston Public Schools Asthma Action Plan Acquisitions Asthma Action Plan Acquisitions Resources and support to BPS nurses: Resources and support to BPS nurses: -Albuterol -Nebulizers -Spacers -Instructional booklets and videos -Scholarships to CHB conferences -Parent/Student/Staff Education Workshops Asthma Action Plan Acquisitions Asthma Action Plan Acquisitions Resources and support to BPS nurses: Resources and support to BPS nurses: -Albuterol -Nebulizers -Spacers -Instructional booklets and videos -Scholarships to CHB conferences -Parent/Student/Staff Education Workshops

Target Population: Four zip codes for Roxbury, Jamaica Plain and Mission Hill Four zip codes for Roxbury, Jamaica Plain and Mission Hill Patients identified for CAI by CHB Emergency room visits, Admissions, provider referral Patients identified for CAI by CHB Emergency room visits, Admissions, provider referral Patients were identified by active visit logs and summaries from billing codes from hospital data bases Patients were identified by active visit logs and summaries from billing codes from hospital data bases Four zip codes for Roxbury, Jamaica Plain and Mission Hill Four zip codes for Roxbury, Jamaica Plain and Mission Hill Patients identified for CAI by CHB Emergency room visits, Admissions, provider referral Patients identified for CAI by CHB Emergency room visits, Admissions, provider referral Patients were identified by active visit logs and summaries from billing codes from hospital data bases Patients were identified by active visit logs and summaries from billing codes from hospital data bases

MethodsMethods Data were collected as part of patient care and parental clinical interviews at baseline, 6 months and 12 months Data were collected as part of patient care and parental clinical interviews at baseline, 6 months and 12 months Data were compared from baseline to 6 or 12 months by McNemar’s test for dichotomous variables, paired t- tests and Wilcoxen sign ranked test for continuous variables. Data were compared from baseline to 6 or 12 months by McNemar’s test for dichotomous variables, paired t- tests and Wilcoxen sign ranked test for continuous variables. Data were collected as part of patient care and parental clinical interviews at baseline, 6 months and 12 months Data were collected as part of patient care and parental clinical interviews at baseline, 6 months and 12 months Data were compared from baseline to 6 or 12 months by McNemar’s test for dichotomous variables, paired t- tests and Wilcoxen sign ranked test for continuous variables. Data were compared from baseline to 6 or 12 months by McNemar’s test for dichotomous variables, paired t- tests and Wilcoxen sign ranked test for continuous variables.

QI Indicators Monitored every 6 months (summed to 12 months) Number of emergency department visits Number of emergency department visits Number of hospitalizations Number of hospitalizations Number missed school days Number missed school days Number of missed work days Number of missed work days Number of days with limitation of physical activity Number of days with limitation of physical activity Number of children with an up to date Asthma Action Plan Number of children with an up to date Asthma Action Plan Average monthly cost of medications (or co-pays) Average monthly cost of medications (or co-pays) Number of emergency department visits Number of emergency department visits Number of hospitalizations Number of hospitalizations Number missed school days Number missed school days Number of missed work days Number of missed work days Number of days with limitation of physical activity Number of days with limitation of physical activity Number of children with an up to date Asthma Action Plan Number of children with an up to date Asthma Action Plan Average monthly cost of medications (or co-pays) Average monthly cost of medications (or co-pays)

Data to Date As of July 1, 2007 As of July 1, patients out of 370 identified (50%) Received Case managementReceived Case management 54.3% are boys,54.3% are boys, Mean age 8.1 years (SD ± 4.5 years)Mean age 8.1 years (SD ± 4.5 years) -113 families home visits (61%) 56 outreach and 95 nurse visits56 outreach and 95 nurse visits 18 families Intensive IPM (25 visits)18 families Intensive IPM (25 visits) -Cost for asthma $1-500/month (mean $92.82) self- or co-pay -Mean days to follow up with primary care SD As of July 1, 2007 As of July 1, patients out of 370 identified (50%) Received Case managementReceived Case management 54.3% are boys,54.3% are boys, Mean age 8.1 years (SD ± 4.5 years)Mean age 8.1 years (SD ± 4.5 years) -113 families home visits (61%) 56 outreach and 95 nurse visits56 outreach and 95 nurse visits 18 families Intensive IPM (25 visits)18 families Intensive IPM (25 visits) -Cost for asthma $1-500/month (mean $92.82) self- or co-pay -Mean days to follow up with primary care SD

Paired T-tests, 6 and 12 months Mean Diff SDP-value ER Visits, 6mo. ER Visits, 12 mo Admissions, 6 mo. Admissions, 12 mo < Missed School days, 6 mo. Missed School Days, 12 mo

Public Policy Advocacy Efforts: Boston Urban Asthma Coalition (BUAC) Boston Urban Asthma Coalition (BUAC) -An Act to Improve Asthma Management ( legislative session) Asthma Regional Council (ARC) Asthma Regional Council (ARC) -Business case for investing in asthma education and environmental interventions -Insurance benefits guides for providers Boston Urban Asthma Coalition (BUAC) Boston Urban Asthma Coalition (BUAC) -An Act to Improve Asthma Management ( legislative session) Asthma Regional Council (ARC) Asthma Regional Council (ARC) -Business case for investing in asthma education and environmental interventions -Insurance benefits guides for providers

ConclusionsConclusions Community Asthma Initiative significantly decreased emergency room visits, admissions, missed school days, missed work days Community Asthma Initiative significantly decreased emergency room visits, admissions, missed school days, missed work days Program improves access to care Program improves access to care Successful model of enhanced asthma care and education that can be replicated nationally Successful model of enhanced asthma care and education that can be replicated nationally Policy changes are in process to support asthma care, home visits, and affordable medications Policy changes are in process to support asthma care, home visits, and affordable medications Community Asthma Initiative significantly decreased emergency room visits, admissions, missed school days, missed work days Community Asthma Initiative significantly decreased emergency room visits, admissions, missed school days, missed work days Program improves access to care Program improves access to care Successful model of enhanced asthma care and education that can be replicated nationally Successful model of enhanced asthma care and education that can be replicated nationally Policy changes are in process to support asthma care, home visits, and affordable medications Policy changes are in process to support asthma care, home visits, and affordable medications