Community Coalition Connects Medical Practices to Community Resources, Leading to Improved Asthma and Diabetes Outcomes in At-Risk Populations

Problem Addressed

• High prevalence of chronic disease in at-risk populations: Diabetes, asthma, and obesity are common problems, especially among low-income, minority populations. For example, in 2002, 30.8 million people had been diagnosed with asthma at some point in their life, with rates particularly high among Puerto Ricans, non-Hispanic Blacks, and American Indians.¹ About 8 percent of the U.S. population has diabetes with rates high among Hispanics (with 10.4 percent having diabetes) and non-Hispanic Blacks (11.8 percent).² More than one-third of U.S. adults were obese in 2005 to 2006; obesity rates are higher among African Americans and Hispanics than among Whites.³ Over the last 15 years, the prevalence of adult obesity more than doubled, while the number of overweight adults increased by 20 percent in King County; currently, almost 60 percent of King County residents who live in the project area for the coalition are overweight, and more than 15 percent are obese.⁴
• Leading to frequent hospitalizations and higher mortality: In 2001, 181.8 out of every 100,000 King County residents who live in the coalition's project area were hospitalized for asthma, including 335 out of every 100,000 children, a rate 2.5 times higher than in the rest of the county.⁴ During that same year, 140.2 out of every 100,000 King County residents who live in the coalition's project area were hospitalized for diabetes, twice the rate of the rest of the county; furthermore, the mortality rate for African Americans in King County who have diabetes is higher than for African Americans in any of the 10 largest U.S. counties.⁴
• Poor health behaviors as a contributing factor: Physical inactivity, poor nutrition, and/or smoking contribute to a number of chronic conditions, including asthma, diabetes, and obesity. Surveys of King County adults indicate that 82 percent do not engage in regular and sustained physical activity; 75 percent do not eat the recommended five servings of fruits and vegetables a day; and 29 percent smoke (compared to 19 percent in the rest of the country).⁴
• Deficiencies in medical and community organizations as a contributing factor: Deficiencies in chronic care in the clinic setting include rushed practitioners who do not always follow established care guidelines, lack of care coordination, lack of active followup, and inadequate training of patients to self-manage their condition.⁵ Deficiencies in the community setting include a lack of resources, coordination and integration of services, and policies that support health.⁴

Description of the Innovative Activity

• Strong Kids: Strong Kids, a collaboration between the YMCA, Seattle Children’s Hospital, and Steps to Health King County, incorporates strategies to promote overall health and well-being for overweight/obese children (ages 8 to 14 years) and families struggling to maintain a healthy lifestyle. Pediatricians refer children and their parents to the program.
• Community health worker (CHW) program: Participating hospitals and clinics refer patients with asthma or diabetes to CHWs, who come from the local community and have experience in managing these conditions. Most people referred have low socioeconomic status. CHWs contact clients to set up an initial in-person meeting, and then make periodic home visits to encourage self-management and provide assessment, education, and action planning. CHWs also promote access to care by encouraging participants to attend their physician appointments and by referring clients to community resources. CHWs update referring physicians via written reports. Steps supports an RN who has responsibility for overseeing the CHWs, both from a clinical and a management standpoint. The practicing general internists who provided oversight to the Steps program also give additional clinical support to the CHWs in the form of periodic case conferences. The RN checks in with the CHWs weekly (in person), and as needed at other times; she is always available by cell phone. Office space for the CHWs is provided by the department of public health.
• ED case management in chronic disease: ED-based registered nurse case managers at Harborview Medical Center manage patients according to detailed, internally developed protocols that include both medical and behavioral components. Case managers link patients to a primary care home and to community resources, including the asthma and diabetes CHWs.  
• Aerobic swim program: This program, created jointly by a health clinic and a community center, refers at-risk individuals (particularly overweight women of color) to a special swim aerobics program held at a local community center. The clinic, which obtained a small grant from a local foundation to cover the costs of participation for low-income residents, reimburses the community center on a monthly basis.

References/Related Articles

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Results

• More physical activity: Among the 41 parent-child dyads who enrolled in the Strong Kids program (out of 94 referrals), pre- and post-implementation surveys show an 11 percent decline in the number of families with more than 3 hours of screen (television and/or computer) time per day and a 35 percent increase in the number of days where parent and child engaged in vigorous exercise.
• Better outcomes for asthma patients: Patient surveys done at program initiation and exit reveal that the percentage of asthma patients seen by CHWs who reported symptom-free days and nights over the previous 2 weeks increased from 8.5 to 12.2 percent; the corresponding increase in symptom-free nights only was from 9.8 to 12.5 percent. The percentage of patients with an asthma-related hospitalization over the previous 12 months decreased from 12 to 5 percent, while corresponding figures for asthma-related ED visits fell from 46 to 21 percent.
• Better outcomes for diabetes patients: Over 250 individuals have been served by the ED case management in chronic disease program to date. Preliminary results for the first 90 patients with diabetes indicate that nearly one-half were connected with a primary care home and, on average, reduced their hemoglobin A1c (blood glucose) levels by 1 percentage point as compared to baseline levels. ED use also declined among patients receiving case management.

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Coalition created: Public health department representatives contacted colleagues in various sectors (schools, universities, health care organizations, and community-based organizations focused on nutrition and/or physical activity) and asked them to "spread the word" about the project to solicit participants. Open meetings were organized for interested parties, who formed the coalition.
• Governance structure designed: Through a consensus process, the coalition created a 15-person leadership team that meets on a monthly basis to review projects, approve funding, and review operations. A smaller executive committee helps with strategic planning and informs the agenda of the leadership team. The leadership team drafted bylaws that were approved by the coalition.
• Project criteria developed: The team outlined an explicit set of criteria/principles (e.g., implementation of evidence-based programming) to govern project approval.
• Sector-specific projects proposed: The coalition membership worked together by sector to develop project proposals. Each sector had multiple meetings to develop a set of recommended interventions.
• Proposals evaluated: The leadership team evaluates proposals and creates a funding priority list; it also locates experts to help guide projects if needed.
• Contracts monitored: A core staff supported by Steps to Health is housed in the public health department, providing administrative oversight of projects and grant funds, contract management, and technical assistance.

Resources Used and Skills Needed

• Costs: The program cost roughly $9 million over a 5-year period, with funds used to support a core team of Steps to Health staff at the public health department and individual initiatives within the community.

Funding Sources

Centers for Disease Control and Prevention

Tools and Other Resources

Getting Started with This Innovation

• Create a formal coalition: The coalition provides a forum for convening different sectors and professionals to talk about common goals and strategies.
• Develop an explicit, well-articulated statement about goals: This provides a framework for future initiatives and informs the selection of individual projects to fund.
• Ensure senior leadership support: In large organizations such as medical centers and government agencies, senior leadership support is critical to the success of the program.
• Cultivate champions: Champions should include both physicians and "bridge" professionals who serve as catalysts and community organizers, bringing entities together to develop initiatives.
• Link medical and community organizations through appropriate operational steps: For example, with any initiative that links medical and community organizations, clinics should be made aware of available community resources. In addition, a formal referral process and standards for communication about referred patients should be designed to ensure a steady flow of referrals and overall clinician support.
• Leverage assets and shared resources: Determine the availability of and access to ready-to-use tools and resources, including patient registries, educational materials and courses, guidelines, community Web sites, and patient support phone lines. These resources can be leveraged and adapted to quickly initiate program services. For example, Harborview Medical Center invited community representatives to participate in its chronic illness courses geared toward allied health professionals.

Sustaining This Innovation

• Require grantees to track and report outcomes periodically: Ongoing tracking and reporting to the coalition will ensure that funded programs are producing results. However, smaller organizations that do not have expertise in data collection and measurement may need to rely on external technical assistance in order to track outcomes rigorously.
• Share control: While community-led efforts can be messy, system change is most sustainable if driven by the community. 
• Ensure ongoing funding and provision of in-kind resources: Initiatives cannot be sustained without funding or other resources. However, funding need not be extensive at the local level. With a modest amount of resources, most communities can leverage existing creativity and energy to produce positive results.