1. Addressing asthma health disparities: Results of a hybrid model linking clinics and coalitions American Public Health Association Annual Meeting November 2013 Terry Greene, MS, Jing Guo, PhD, Laurita Kaigler- Crawlle, Jean Kelley, MD, Barbara Rogers, NP, Matthew Sadof, MD and Jean M. Zotter, JD, Principal Investigator

2. Presenter Disclosures (1)The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: Terry A. Greene, M.S. No relationships to disclose.

3. *This work was supported by CDC Cooperative Agreements #5U59EH0005-05. Contents are solely the responsibility of the authors and do not necessarily represent the official views of CDC or MDPH. This evaluation was funded and fully supported by the Massachusetts Department of Public Health to assess their Asthma Disparities Initiative.

4. Acknowledgements Boston Healthy Homes & Schools Collaborative Pioneer Valley Asthma Coalition Centers for Disease Control and Prevention High Street Health Center Dorchester House Multi- Service Center Boston Public Health Commission

5. Introduction A two and a half year initiative Goal: To reduce racial and ethnic pediatric asthma disparities among Black and Hispanic children regionally by delivering –asthma self-management education, –home trigger assessment, and –promoting local policies that reduce exposure to triggers and improve asthma self-management. MDPH Asthma Disparities Initiative (ADI)

6. Clinics + Community Coalitions Collaborate Sharing of resources Coordinated programming Joint outreach Leveraged policy advocacy Community Health Workers (CHW) Support families at the health centers Conduct patient home visits Further the work of the community coalitions Recruit family members of children with asthma to participate in coalition activities. The Hybrid Model

7. Improved: management; quality of life; health outcomes Asthma Education Trigger-Free Environments Protective Policies Logic Model Clinic Community Health Worker Coalition

8. Two Pilot Sites Springfield, MA –Baystate Children’s Hospital’s High Street Health Center Pediatrics Clinic (High Street) –Pioneer Valley Asthma Coalition (PVAC) Boston, MA –Dorchester House Multi-Service Center (Dorchester House) –Boston Healthy Homes & Schools Collaborative (BHHSC), a program of Health Resources in Action (HRIA) –Technical Assistance from the Boston Public Health Commission (BPHC)

9. Evaluation Methods Qualitative analysis –Document review: Bi-annual grant reports, –Key informant interviews, –Site visits, and –Monthly ADI Technical Assistance conference calls engaging both pilot sites. Quantitative analysis –Outcomes at Dorchester House.

10. Results

11. How Has the Model Bridged The Gap Between Families and Providers? Improved understanding of context of patients’ lives The CHWs “get into homes to get a real sense of what is happening and bring that knowledge back into the clinic, both directly through patient records and indirectly as a member of the clinical team.” - Clinician

12. How Has the Model Bridged The Gap Between Families and Providers? Improved Asthma Self-Management The one-on-one individual time with the parents and children was so important to let them know that they did not have to feel handicapped – that they can still live productive lives if they just manage their asthma. - CHW

13. Expanded Asthma Awareness Increased awareness of asthma as a public health problem.

14. Boston Outcomes Shifts in the level of asthma control (based on self-reports) from poorly or not well controlled to well controlled. Reductions in home trigger factors (especially pests). Apparent reductions in: ER visits, hospitalizations, and urgent care use; although tracking was over a very short time period.

15. Springfield Outcomes Springfield Asthma Action Plan Project 2009-2011 Students with asthma Students with asthma medication orders Students with Asthma Action Plans % of students with asthma medication orders who have Asthma Action Plans Pre-Intervention5200780 (15%)9 (0.2%)1.1%* Post-Intervention52881327 (25%)449 (8.5%)33.8%* *Pearsons' chi-square test for both values: p < 0.0001

16. Additional Findings on Forging Connections Improved Access to Resources Sharing of Clinical and Community Knowledge Success of Collaboration Varied among Sites “It’s hard to treat asthma in a vacuum. You need to know resources around you to help patients and the coalitions provided that link... They helped us figure out what the issues were… It also helped us develop better communication with the school system.”- Clinician

17. What Systems Level Improvements Resulted from the Collaborations? Community-wide changes New and/or improved local asthma policies “ADI gave us the model and a baseline of funding that allowed us to build the capacity and relationships to effect change.” – Coalition Director

18. New and/or Improved Local Asthma Policies Addressing Social Determinants and Improving Housing Conditions Improving School Environmental Health Local Policy Support “ADI provided the framework for clinic- community engagement to improve conditions and care for those with asthma, and the community embraced the problem.” – Coalition Director

19. Community-Wide Changes Capacity-Building for Asthma Initiatives Identification of Asthma Champions Strengthening Community Leadership “Most of our focus has been on systems change and policy adherence or enhancement. We’ve been able to transfer ownership of environmental health from the community coalitions to the local school departments.” – Boston Coalition Director “We are looking to develop champions for every low- income housing development within Springfield.” – Springfield Coalition Director

20. Clinical Practice Improvements Improved Clinical Referral Networks Preventative Asthma Care “What happens is that patients will come in to the clinic earlier and don’t have to go to the ER. They are not as sick and are using the ER less.” – Clinician Home Visits “Most of the families felt more comfortable in their home environment…and the next visit in the clinic was more relaxed because [the clients] were more relaxed. – CHW

21. What Infrastructure is Needed to Support CHW in Asthma Interventions? CHW and other staff orientation and training to help prepare for CHW : 1)Participation in the community coalition 2)Performance of home visits (including issues such as personal safety) 3)Integration into the asthma provider team, and 4)Provision of patient asthma education “We were very well trained before we went out to the community… I never pretended that I knew everything – I got back to the families with the information they were seeking.” – CHW

22. Future Needs/Opportunities Children's High Risk Asthma Bundled Payment Demonstration Certify CHWs and reimburse their services by insurers Prevention/Wellness Trust Fund Leveraged Grants “We need to be able to certify CHWs so they are recognized and reimbursed by insurers in a way that respects [their vital contributions to] cultural competency.” – Clinician

23. In Their Words… “The program worked – it changed use of medications, changed the child’s life, and the parent’s life. I saw what it did for every family and individual. I think the program is awesome and should be nationwide! Because we need more advocacy and programs [so people know] how to be in control of asthma and not feel hopeless... I thank the program and the coalition because that made a difference in many people’s lives.” - CHW

24. Contact Info Jean Zotter, JD, Director Office of Integrated Policy, Planning and Management; 617-994-9807 Jean.Zotter@state.ma.us Massachusetts Department of Public Health (MDPH) 250 Washington Street Boston, MA 02108 http://www.mass.gov/dph/ohsp http://www.mass.gov/dph/asthma Erica Marshall, MPH, Director Asthma Prevention and Control Program (617) 624-5401 Erica.Marshall@state.ma.us Terry Greene, M.S. Consultant Evaluator to the MDPH Asthma Prevention and Control Program JSI Research & Training Institute, Inc. (617) 385-3835 Tgreene@jsi.com http://www.jsi.com