National Environmental Leadership Award in Asthma Management

Mobile Care Chicago (MCC) fills the gap in specialty medical care access for children across Chicago. To address cost and transportation - two of the most commonly cited barriers to asthma care -in 1998, four physicians converted Winnebago RV vans into mobile clinics that are taken in the highest need neighborhood to offer care at no cost. The program has grown from a partnership with two Chicago Public elementary schools to 45 Chicago public schools, parochial schools, and Head Start programs. Mobile Care’s Comprehensive Asthma Management Program is now staffed by an allergist, three nurse practitioners, a medical assistant, a care coordinator and an asthma educator (CHW). MCC partners with the American Lung Association of the Upper Midwest to provide in-home asthma assessments and a wide-range of supplies including furnace filters, cleaning supplies and IPM. MCC’s Comprehensive Asthma Management Program has seen a 50% decrease in school absenteeism and emergency department visits and realizes a three-fold return on investment. MCC receives funding from several sources including insurance reimbursement (50%), foundations and individuals.

Omaha Healthy Kids Alliance (OHKA) is a children’s environmental health organization dedicated to improving children’s health through Healthy Homes. Several years ago, OHKA launched the Asthma In-Home Response (AIR) Program serving children ages 18 and younger that have asthma or an asthma-related diagnosis. AIR currently has formal partnerships with WellCare of Nebraska (Nebraska managed care organization), Children’s Hospital and Medical Center, and Boys Town Allergy, Asthma, Immunology and Pediatric Pulmonary Clinic. Home visits are performed by two OHKA staff who are trained in environmental management and asthma education. In addition to a customized environmental supply kit, families are often referred to community organizations for legal and employment services or food pantry access. AIR participants have shown a significant decrease in symptom days, missed school days, ED visits and hospitalizations, and for every $1 invested OHKA realized a Return on Investment (ROI) of $1.83. Children’s Hospital currently reimburses OHKA $1,500 for every completed asthma intervention which directly supports the sustainability of this program for Omaha, and eventually for the state. AIR’s newest partnership with WellCare of Nebraska creates another, more sustainable funding mechanism.

Rhode Island Asthma Control Program (RIACP) serves children with asthma ages 0-17 in high poverty, urban cities in throughout the state. RIACP has strong partnerships with Hasbro Children’s Hospital, St. Joseph Health Center, New England Asthma Regional Council and Green and Healthy Homes Initiative among others. In 2010, RIACP established the evidence-based Home Asthma Response Program (HARP), which uses certified asthma educators and community health workers (CHWs) to conduct up to three intensive in-home sessions, including tailored environmental services. Over the visits, CHWs reported reductions in mold, pests, dust, pets, and tobacco smoke. Using hospital claims data, HARP participants had a 75% reduction in asthma-related hospital and ED costs. For every $1 invested in HARP participants, the program realized a $1.33 Return on Investment (ROI). In 2018, RIACP received confirmation of approval for $300,000 in Volkswagen Clean Air Act Civil Settlement funds that will be used to expand HARP home visiting services statewide for Medicaid-enrolled children. Also, in 2018, RIACP partnered with UnitedHealthcare (UHC) to fund a pilot intervention with HARP-eligible UHC-Medicaid. Partnering with a managed care organization will allow RIACP to promote the adoption of home visiting services into other managed care health insurance plans.

The Zuckerberg San Francisco General Hospital Pediatric Asthma and Allergy Clinic (PAAC) was created in 1999 in response to San Francisco’s unusually high asthma hospitalization rates. More than just a clinic, the PAAC is a comprehensive asthma management program built upon a medical-social model of subspecialty care. At the heart of the program is the community health worker (CHW) who acts as a powerful patient advocate and a liaison between the community and the clinic. The patient population PAAC serves is approximately 62% Latino, 18% African-American and 12% Asian. During home visits, culturally-sensitive CHWs address common environmental asthma triggers and through partnerships with San Francisco Department of Public Health and other key organizations, CHWs offer support for a variety of other issues that face these families. PAAC also works with schools and daycare centers to reduce indoor triggers and improve communication between families and schools regarding asthma treatment plans. As a subspecialty clinic within the county hospital, the PAAC receives funding from Medicaid reimbursement, giving them inroads for conversations regarding reimbursement for home visits. All of PAAC’s efforts have paid off yielding a 40% reduction in asthma hospitalizations in a review of data from 2015-2016.

The Community Asthma Prevention Program (CAPP) at the Children’s Hospital of Philadelphia (CHOP) has focused on disparities in childhood asthma in West Philadelphia for 20 years and has grown to provide asthma self-management education in all sectors of the child’s life including home, community, school, and health care environments. CAPP’s community health workers (CHWs) are recruited from the very community they serve, which is primarily Black/African American and Hispanic. CAPP has established strong relationships with Philadelphia Housing Authority, the Pennsylvania Department of Health and the Philadelphia School District in order to provide comprehensive services to the families they serve. The CHWs are among few nationwide to be reimbursed by health insurance companies for home visits, and as CHOP employees, they also have access to the hospital’s electronic medical health record system in order to help coordinate care and better advocate for necessary services. In an evaluation of 2010-2014 data, CAPP’s program success realized a 62% reduction in emergency visits and a 70% reduction in hospitalizations.

Children’s Hospital of Richmond at VCU’s You Can Control Asthma Now (UCAN) community asthma program helps children who live in the Richmond, Virginia, metropolitan area where both asthma and poverty rates are disproportionately high. Established in 2015, UCAN has served more than 344 patients using a family-focused case-management approach. Families are typically enrolled following an uncontrolled asthma-related emergency room visit or hospitalization, but can also be referred by their primary care physician or self-refer. UCAN patients are assigned a pulmonologist (lung doctor) who provides comprehensive asthma care, receive asthma education from a nurse, and are provided resources and support to address barriers to treatment following evaluation by a social worker. They receive follow up communication via text and phone calls, and are referred as needed for a Healthy Homes assessment through the City of Richmond Health District. UCAN also collaborates with the Medical Legal Partnership Program to empower families to address environmental housing issues not properly addressed by landlords. UCAN has saved $691 per patient through decreased hospitalizations and emergency room visits – leading to an overall cost reduction of $163,958.

Esperanza Community Housing Corporation (Esperanza) serves the communities located in South Los Angeles, an area that is home to almost one million residents and one of the most economically disenfranchised areas in the County of Los Angeles. Founded in 1989 out of a successful community organizing campaign to prevent the displacement and housing vulnerability of tenants, Esperanza has grown to become a national leader in advancing the Promotores de Salud (Community Health Promoters) Model in targeting health disparities, improving health, and increasing access to health services for community residents. Since 1995, Esperanza has trained and mobilized 474 Promotores de Salud, through an intensive 6-month training, to provide culturally accessible primary prevention, health education and advocacy services to families and children in South Los Angeles. In 1998, Esperanza began cultivating its Healthy Homes collaborative to address primary prevention of lead poisoning and other housing-based hazards, in a multi-layered approach to mitigating environmental health hazards in the home. Recognized as a National Healthy Homes Leader, Esperanza established the Healthy Breathing Program which uses a Healthy Homes approach in its home-visitation model to focus on the identification of asthma triggers, iterative health education, and management of asthma episodes in the home.

Along with their team of Promotores, Esperanza’s Healthy Breathing Program partners with federally qualified health centers, local hospitals, and clinics to provide comprehensive services to asthma patients throughout the year. Esperanza’s Healthy Breathing Program features repeated in-home visits and a year-long patient evaluation; identifies and helps control in-home asthma triggers; and, provides in-depth asthma education for patients, household members, and caregivers. The program strives to enroll at least 500 pediatric and adult asthma patients every three years. These efforts have led to improvements in prescription adherence, increases in the number of patients with asthma action plans, reduction in severe asthma episodes, and more efficient referrals to medical homes and wrap-around services. The Healthy Breathing Program provides valuable cost savings by reducing the number of unnecessary emergency room visits. A 2012 analysis of a single emergency department saw more than 1.4 million dollars in savings by utilizing preventative in-home and outreach education.

Health Care Service Corporation (HCSC), the nation’s largest customer-owned health insurer, in partnership with the American Lung Association of the Upper Midwest (ALAUM), has implemented comprehensive, community-based asthma quality improvement programs in more than 120 health care clinics in Illinois, Montana, New Mexico, Oklahoma and Texas. The program have served an estimated 435,545 individuals across these states, including low-income, Latino, and Native American populations. The ongoing effort works directly with providers to improve the quality of care being delivered to patients with asthma, in addition to direct engagement with individuals through home environmental assessments that include asthma education and providing allergen-reducing and remediation products. The company leverages its own medical claims data to identify providers serving the highest-risk children with asthma and the ALAUM invites these clinics to take part in a year-long learning collaborative and training program based on the National Asthma Education Prevention Program developed by the National Heart, Lung, and Blood Institute. Overall, hospitalizations for children years 18 and younger have reduced by 59 percent and emergency department (ED) visits have been reduced by 54 percent. For individuals older than 18 years, results showed a 52 percent reduction in hospital stays and a 56 percent reduction in ED visits for this population. The program has also realized a positive return on investment – a savings of $2.40 per dollar spent. Not only are patients able to better manage their asthma, but significant reductions in avoidable medical utilization drives down the cost of care for all and allows the company to play a vital role in making the health care system work.

AmeriHealth Caritas, through its local affiliate, has implemented a comprehensive asthma management program to serve Medicaid recipients and their families living in southeastern Pennsylvania. Care managers and support staff apply a sustainable approach based on population health, guiding members through a continuum of care that is built on solid evidence and works within AmeriHealth Caritas’ integrated health care management system. High-risk members are identified for individual care management assessment, care planning and interventions focusing on priority areas (i.e., asthma control action plan, sick day plan, medication management, behavioral risk management and asthma self-management). Members and network providers can participate in several unique, award-winning initiatives that support the delivery of asthma medication and supplies, asthma education, and home environmental surveys. AmeriHealth Caritas partnered with the local affiliate’s network providers to adopt unique community health worker (CHW) models in northeast Philadelphia, west Philadelphia and Chester tailored to the local demographic and fiscal environment. Trained CHWs, supervised by a medical director, cooperate with the practice- and telephone-based care management system to provide face-to-face care coordination, home health and environmental surveys, and asthma-related education for members and their families while addressing the social determinants impacting members’ health. When environmental asthma triggers are identified, the CHW may deliver “asthma home kits” (including hypoallergenic mattress and pillowcase covers) and suggest such actions as conducting mold remediation. Additional service offerings include provider-led dispensation of asthma medication and supplies and hands-on education during office visits (B.E.S.T. asthma program—Breathe Easy. Start Today.®); school-based clinic partnerships to address member care gaps in asthma medication adherence; and “edutainment” programming (Healthy Hoops®) for children with asthma and their families.

During its 20-year history, the King County Asthma Program (KCAP) at Public Health—Seattle & King County has pioneered research and programs in asthma management. Under the guidance of Dr. Jim Krieger, KCAP developed its core programming: home visits with community health workers (CHWs) to reduce asthma triggers in homes and improve asthma outcomes. For 20 years, KCAP’s projects and research have helped build the solid evidence base for this model, which now informs asthma services offered across the nation. To build this program, KCAP program staff have worked with care providers in public health settings, hospital systems, community clinics, health plans, academic institutions, schools, housing agencies and community organizations. Since its original demonstration project began in 1997, KCAP has engaged more than 4,000 patients in programs to manage environmental asthma triggers and improve care delivery for better health outcomes. These efforts have contributed to decreases in asthma-related hospitalizations and urgent care use, increases in patient and caregiver quality of life, and a greater overall return on investment when compared to standard care. KCAP continues to build the evidence base for the CHW model and patient-centered asthma care, and it serves as an exemplar for asthma care delivery across Washington state and nationwide.

Organized by Heath Resources in Action’s Asthma Regional Council (ARC), the New England Asthma Innovation Collaborative (NEAIC) is a multisector initiative covering four states: Connecticut, Massachusetts, Rhode Island and Vermont. Funded by the Center for Medicare and Medicaid Innovation (the Innovation Center), NEAIC was designed to support infrastructures that deliver home visiting services to primarily Medicaid and State Children’s Health Insurance Program (CHIP)-enrolled children (ages 2–17) with poorly controlled asthma. NEAIC has trained clinical staff and community health workers (CHWs) to provide cost-effective, high-quality and culturally competent asthma home visiting services. CHWs—supervised by a nurse or certified asthma educator—have provided three to four home visits for 1,145 children, educating their caregivers and delivering low-cost supplies to help families reduce environmental asthma triggers. Through the efforts of the CHWs, NEAIC has seen a substantial decrease in hospital admissions and urgent care visits and a reduction in missed school days and work days because of asthma. Though Innovation Center funding has concluded, several provider sites are continuing CHW services, and NEAIC continues to promote sustainable financing for these important efforts.

Urban Health Plan (UHP) is a network of nine community health centers and nine school-based health centers located in the South Bronx, NY—the poorest congressional district in the country—and Corona, Queens, NY. Located within UHP’s catchment area, in Hunts Point, Bronx, is the largest food distribution center in the country. As a result of the traffic and pollution generated by the trucks used to distribute food, Hunts Point has one of the highest asthma rates in New York City. Asthma Relief Street, UHP’s asthma management program, cares for more than 12,000 people with asthma using a multidisciplinary program that is fully integrated into its primary care practice. Asthma patients are assessed, treated and educated at every visit, whether they come for well-child care, a followup, or a sick walk-in visit. UHP has a robust asthma education program, with health educators located at all of its sites and in all departments. UHP’s health educators follow an asthma curriculum that was developed by UHP clinicians. It includes five lessons: (1) definition of asthma (2) the signs and symptoms of exacerbations (3) recommendations on remediation in the home to address environmental triggers (4) differences between "controller" and "rescue" medications (5) and understanding of spirometry and exhaled nitric oxide. The health educators work collaboratively with New York City Asthma Intervention and Relief (a.i.r. nyc) on home intervention and pest management programs. UHP also is one of the early adopters of nitric oxide testing in patient evaluations, which helps to diagnose asthma, measure response to steroid therapy and level of inflammation control, and monitor adherence to treatment. The program distributes nebulizers onsite and ensures that families have the skills to use them correctly. For patients with severe and uncontrollable asthma, both an allergist and a pulmonologist are on site. UHP’s Asthma Relief Street Program has resulted in improved asthma outcomes and has been sustainable and cost-effective for more than 15 years.

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.

GHHI provides an innovative approach to addressing substandard housing by braiding together categorically separate but mission-related funding and programs, and by leveraging federal, state, local and philanthropic resources to create healthy, lead-safe and energy efficient homes across America. Launched in partnership with the U.S. Department of Housing and Urban Development, the US Centers for Disease Control and Prevention, and the White House Office of Community Initiatives in 2009, GHHI is effectively transforming the housing intervention system at the local level.

The Green & Healthy Homes Initiative (GHHI) serves low-income families living in Baltimore City, Maryland, who face a higher than average rate of asthma prevalence, hospitalizations, emergency visits and deaths compared with other Maryland regions and the nation as a whole. Working through a coalition of 35 federal, state, local, nonprofit, university and philanthropic partners, GHHI uses a transformative asthma management model that combines in-home family asthma education; a comprehensive health, safety and home energy audit; and root cause remediation. Since 2000, GHHI Baltimore has completed housing interventions in 1,118 homes of patients diagnosed with asthma in Baltimore City.