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Service Delivery Innovation Profile

Hospital–Community Organization Partnership Uses Culturally Competent Community Health Workers To Support Latino Families With Asthmatic Children, Reducing Hospitalizations and Emergency Department Visits


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Snapshot

Summary

In a partnership between four community-based organizations and NewYork–Presbyterian Hospital and Columbia University Medical Center, community-based, bilingual community health workers support low-income, predominantly Latino families of children with asthma in better management of the disease. Known as the Washington Heights/Inwood Network for Asthma Program, the initiative features home visits to identify environmental triggers and provide comprehensive asthma education and ongoing telephone and face-to-face contact for 1 year. The asthma program has increased families' use of asthma management strategies and enhanced confidence in their ability to manage the child's disease, leading to significant reductions in asthma-related symptoms, hospitalizations, emergency department visits, and missed school days. In 2012, the program was expanded to include similar education and support for adults with diabetes. Preliminary results from the diabetes program showed decreases in glycated hemoglobin, blood pressure, and low-density lipoprotein.

See Description and Results for new information about the expansion of the program to include adults with diabetes (updated November 2013).

Evidence Rating (What is this?)

Moderate: The evidence consists of comparisons of various asthma-related metrics collected at enrollment and 1 year afterward, including caregiver self-efficacy; use of asthma management strategies; and asthma-related hospitalizations, ED visits, school absences, and symptoms.
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Developing Organizations

NewYork-Presbyterian Hospital and Columbia University Medical Center
NewYork–Presbyterian Hospital and Columbia University Medical Center developed the program in conjunction with Northern Manhattan Improvement Corporation, Community League of the Heights, Dominican Womens Development Center, and Fort George Community Enrichment Center.end do

Date First Implemented

2006
Community health workers began enrolling families in September 2006.begin ppxml

Patient Population

The participant population is 93 percent Latino, 6 percent African American, 5 percent white, and 5 percent other.Vulnerable Populations > Children; Race and Ethnicity > Hispanic/latino-latina; Vulnerable Populations > Impoverished; Urban populationsend pp

Problem Addressed

Asthma represents a large, growing problem, particularly for low-income, urban children who are often exposed to multiple indoor allergens and irritants that contribute to asthma-related morbidity. Although management of environmental triggers and proper use of medication reduces such morbidity, many families of children with asthma have difficulty accessing local health resources and do not follow recommended strategies for managing the disease.
  • A large, growing problem: An estimated 20 million Americans suffer from asthma, an increase of 4.3 million (roughly 25 percent) since 2001.1 An estimated 7 million children have asthma,2 which is the most common cause of childhood disability. The prevalence of childhood asthma has increased 232 percent since 1969, more than double the 113-percent increase in other childhood chronic conditions.3
  • Low-income, urban, and minority children  disproportionately affected: Low-income, urban, and minority children are especially likely to suffer from asthma and its related complications.4 Rates of pediatric asthma are higher among African Americans (15.6 percent) and Hispanics (9.4 percent) than among whites (7.7 percent).5 These children are also more likely to suffer asthma-related health problems, as they are disproportionately affected by environmental factors such as cockroach antigens, dust mites, pet dander, and other indoor allergens and irritants. For example, a study of asthma-related health problems in urban children in eight cities found that those exposed to high levels of allergens had more hospitalizations, unscheduled medical visits, days of wheezing, missed school days, and nights with lost sleep than did asthmatic children with low allergen exposure.6 The rate of pediatric asthma-related emergency department (ED) visits in Northern Manhattan, which has a large population of Hispanics, is about four times the national average.7
  • Unrealized potential of better management of environment and medication: Research has demonstrated the effectiveness of having health care workers make home visits to help families eliminate asthma triggers and learn to use medications properly. For example, the Inner-City Asthma Study, a randomized trial conducted in seven U.S. cities, found that home-based asthma education and remediation of allergens reduced in-home allergen levels and symptomatic days,8 whereas the Yes We Can Urban Asthma Partnership, a San Francisco program in which community health workers make home visits, increased prescribing and appropriate use of controller medications, leading to a decline in asthma symptoms.9 However, relatively few asthma management programs include in-home visits.

What They Did

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Description of the Innovative Activity

In a partnership between four community-based organizations and NewYork–Presbyterian Hospital and Columbia University Medical Center, community-based, bilingual community health workers support low-income, predominantly Latino families of children with asthma in better management of the disease. Known as the Washington Heights/Inwood Network (WIN) for Asthma Program, the initiative features home visits to identify environmental triggers and provide comprehensive asthma education and ongoing telephone and face-to-face contact for 1 year. In 2012, the program was expanded to include similar education and support for adults with diabetes. Key program elements are outlined below:
  • Extensive upfront and ongoing training: Before beginning work, community health workers receive extensive training, including 2 weeks of classes about asthma and its treatment and several months of learning to work with families in health care settings and at home. During these sessions, community health workers learn how to conduct hospital rounds and home environmental assessments, administer surveys and manage the information received from them, and motivate children and family members to take charge of their health. Once on the job, community health workers receive ongoing training as needed, such as a recent session about alternative medicine that program leaders developed to encourage participants to discuss home remedies they use with their providers.
  • Eligibility and referrals of target population: The program targets families of children (from newborns through age 18) with poorly controlled asthma. Families are eligible if, within the previous year, their child made two or more ED visits, had one or more hospitalizations, or missed five or more school days because of asthma-related problems. All children admitted to the hospital with an asthma diagnosis are automatically referred to the program, and ED physicians and pediatric physicians and nurses at health clinics affiliated with the hospital are encouraged to refer patients with asthma to the program. In addition, community health workers regularly attend education programs (such as health fairs) held at schools, daycare centers, and community events in an effort to identify eligible families. Parents who hear about the program through word of mouth can also call the program's hotline to learn more about it and enroll.
  • Enrollment: In cases in which patients were admitted to the hospital, community health workers usually visit them and their family at the hospital the same day to enroll them in the program. In other cases, the community health worker telephones the family within 24 to 48 hours of the referral to confirm their eligibility and the family's interest in enrolling. From the program's inception in September 2006 through July 2013, more than 900 families have enrolled in the program. (Updated November 2013.)
  • Assignment to culturally competent community health worker: Each enrolled family is assigned to one culturally competent lead community health worker who acts as a single point of contact for the families. All community health workers speak both English and Spanish, live in the local community, and are skilled at providing culturally appropriate education and services. Many are Latino, the most common ethnicity among enrolled families, giving them insight into the struggles these families face and how to work with them in a manner likely to be well received.
  • Year-long support in managing disease: The community health workers are established members of the Health Care Team and move fluidly between the hospital in-patient units, the clinics, and the community. Over the course of 1 year, community health workers work with families to help them manage their child's disease. Services are divided into three stages, with the first 3-month period featuring the most intense education and support, including at least weekly contact. Over time, support becomes less intense, focused primarily on monitoring and keeping families and patients on track. More details on each phase appear below:
    • Stage one—Intense support: The first 3 months feature intense support designed to help the family manage the child's asthma. Key components are outlined below:
      • Initial, comprehensive home visit: Within 1 week of enrollment, two community health workers (the lead community health worker and a second who provides support) visit the child's residence for several hours to provide comprehensive asthma education. During the visit, the lead community health worker reviews the physician's instructions, making sure the family understands how and when to use quick-relief and controller medications, and helps them set short- and long-term goals, such as avoiding ED visits and missed school days. The lead community health worker also assesses the home for potential asthma triggers, such as pest infestations, pet dander, and tobacco, and discusses how the family can reduce or eliminate any that are identified. For example, the community health worker may show the family how to seal up access points for cockroaches or refer parents to an affordable pest control specialist. The community health worker gives the family a summary list of identified triggers and instructions on how the family can address them. During this visit, the community health worker also works to dispel any myths the family may have about asthma, such as that children with asthma should stay indoors as much as possible and avoid all physical activity, or that asthma is contagious.
      • Weekly telephone calls: For the first 3 months, the lead community health worker calls the family at least once a week to see how they are faring and help with any asthma-related problems they may be encountering.
      • As-needed face-to-face meetings in home, clinic, or hospital: Depending on the child's progress, the lead community health worker may meet with family members again in person, either at the child's home, at the community-based organization, or during or after a visit to a health clinic or the hospital. For example, if a community health worker learns from reviewing hospital records or from a family member that a child was hospitalized because of asthma symptoms, the community health worker may arrange to meet with the family at the hospital or at the organization post-discharge. Staying in regular contact with families, physicians, and nurses allows the community health workers to keep up to date on the child's condition.
    • Stage 2—Moderate support to reinforce education, keep family on track: During the next 3 months, the lead community health worker telephones the family at least once a month to reinforce points from the initial education session, see whether the child is meeting his or her goals, and provide referrals to clinical and social services as needed. At the 6-month mark, the family fills out a survey covering issues such as the child's current asthma symptoms, the presence of household triggers, and the frequency of ED visits.
    • Stage 3—Less intense support: During the final 6 months, the lead community health worker provides similar services as in stage 2, with the frequency of check-in telephone calls now reduced to a minimum of 1 call every other month.
    • Graduation: At the 1-year mark, the family fills out the survey again and participates in a graduation ceremony in which children who have their asthma under control receive a certificate commemorating their achievement. After graduation, families' formal participation in the program ends, but they are still encouraged to call their community health worker if they have questions or problems.
  • Monthly workshops: In addition to receiving support from their community health worker, families can attend 2-hour, monthly bilingual asthma education workshops at the community-based organizations. During these workshops, which are open to the entire community, the program's medical director reviews asthma management strategies, and attendees share tactics that work for them.
  • Diabetes expansion: Information provided in November 2013 indicates that 200 patients have enrolled in the diabetes management program since January 2012. The program follows the same model as the asthma program.

Context of the Innovation

Located in northern Manhattan, NewYork–Presbyterian and Columbia University Medical Center is one of five hospitals in the NewYork–Presbyterian Hospital system. An academic hospital affiliated with Columbia University's College of Physicians and Surgeons, the hospital serves a largely low-income population, many of whom are immigrants from the Dominican Republic, Haiti, and West Africa. Surveys have found that the rate of pediatric asthma-related ED visits in Northern Manhattan is about four times the national average.

The four participating community-based organizations (Dominican Women's Development Center, Northern Manhattan Improvement Corporation, Fort George Community Enrichment Center, and Community League of the Heights) provide a range of social services to local residents, such as employment and literacy training, domestic violence prevention, and legal aid.

Before the program's inception, the hospital already had ties with the community-based organizations, having partnered on various outreach and service initiatives in the community. Aware of the high frequency of repeat ED visits and hospitalizations due to pediatric asthma and the community-based organizations' ability to connect with families at the grassroots level, hospital, university, and community leaders sought funding to establish a community-oriented program to address these problems.

Did It Work?

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Results

The program has increased families' use of asthma management strategies and enhanced confidence in their ability to manage the child's disease, leading to significant reductions in symptom flare-ups, hospitalizations, ED visits, and missed school days. Preliminary results from the diabetes program showed decreases in glycated hemoglobin (A1c), blood pressure, and low-density lipoprotein (LDL).
  • More use of asthma management strategies: The proportion of families taking steps to reduce potential asthma triggers in the home increased by 22 percent, rising from 63 percent at enrollment to 81 percent at graduation (updated November 2013).
  • Greater caregiver and patient self-efficacy: The proportion of caregivers who said they felt in control of their child's asthma rose from 63 percent at enrollment to 97 percent at graduation, an increase of 35 percent. Retention for the diabetes program was at 94 percent at the 6-month mark and 96 percent at the 12-month mark. (Updated November 2013.)
  • Fewer symptoms: The proportion of children reporting asthma symptoms such as daytime wheezing, chest tightness, or cough in the last month fell from 78 percent at enrollment to 51 percent at graduation, a 35 percent decline (updated November 2013).
  • Fewer hospitalizations, ED visits, and missed school days: The proportion of children hospitalized overnight due to asthma fell from 40 percent during the year before enrollment to 14 percent during the year of enrollment, a 65 percent decline. The proportion visiting the ED also fell markedly, from 81 percent to 37 percent, as did the proportion missing school because of asthma (82 percent to 49 percent).  (Updated November 2013.)
  • Improved control for patients with diabetes: Of the 40 patients who completed the year-long diabetes program, there was an average decrease in A1c of 55 percent, a 54 percent decrease in systolic blood pressure, a 43 percent decrease in diastolic blood pressure, and a 50 percent decrease in LDL (updated November 2013).

Evidence Rating (What is this?)

Moderate: The evidence consists of comparisons of various asthma-related metrics collected at enrollment and 1 year afterward, including caregiver self-efficacy; use of asthma management strategies; and asthma-related hospitalizations, ED visits, school absences, and symptoms.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Securing 4-year grant: In 2005, a team of hospital, university, and community leaders successfully applied for a 4-year, $2 million grant from the Merck Childhood Asthma Network, enabling them to begin organizing the program.
  • Organizing program: Throughout 2005, the team met regularly with leaders from the four community-based organizations to discuss how the program would work. Participants agreed that each organization would hire one community health worker for the program, with all hiring decisions approved by both the hospital-based program director and the relevant community-based organization. Although there were no minimum education requirements, all community health workers had to have at least 2 years of experience working in the community.
  • Hiring and training community health workers: After working together to develop a training curriculum, the partners jointly recruited, hired, and trained the four community health workers in 2006, using the extensive training program outlined earlier. The community health workers were cross-trained to serve both pediatric and adult populations.
  • Expanding program to adults with diabetes: In 2010, the program expanded to become WIN for Health, enabling it to expand services to adults with diabetes. The community health worker supervisor now also supervises four additional community health workers (employed by the same four community-based organizations) who help adults with diabetes learn to manage their disease using the same general model as the asthma program.

Resources Used and Skills Needed

  • Staffing: The asthma program's main staff include a manager, community health worker supervisor, four community health workers, and a data specialist. The hospital's pediatric medical director and its clinical director for adult care play an active role in curriculum development and deliver training. Each community health worker handles 30 to 35 families at a time, with about one-third of their caseload receiving intense care (stage one) and the rest being monitored periodically (stages two and three).
  • Costs: The combined annual cost of the asthma and diabetes programs (which use many of the same resources) totals roughly $750,000.
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Funding Sources

Merck Childhood Asthma Network; NewYork-Presbyterian Hospital
The Merck grant funded the program for its first 4 years (2005 to 2009). When the grant ended, NewYork–Presybterian Hospital began funding the program from its internal operating budget. Although the community-based organizations employ the community health workers, the hospital provides funds to each organization to support the community health workers' salaries and benefits. The hospital also provides each organization with funds for a stipend for each community health worker's supervisor and funds for overhead costs.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Define partner roles: Before the program begins, hospital staff should meet frequently with leaders of the community-based organizations to clarify issues, such as how community health workers will perform their jobs and how they will be supervised. Since each organization has its own policies and unique culture, effective communication is critical to ensure that community health workers handle their job responsibilities in a generally similar fashion.
  • Train community health workers: Prepare a comprehensive training plan for community health workers that starts with initial trainings in such areas as core competencies, disease 101, case management, motivational interviewing, and integrated pest management; and continues with refresher sessions throughout the year.
  • Perform home visits in pairs: Having two community health workers conduct home visits makes these trips safer and more effective. The observing community health worker is in a good position to evaluate how well the family is absorbing the information (and to intervene if they appear to be struggling to understand it), and can make sure that the lead community health worker does not overlook any important points.

Sustaining This Innovation

  • Plan for long term: Programs with multiple partners often end once the initial grant funding ends, even when they are successful. To avoid this fate, program leaders should plan for the post-grant phase from the outset by applying for additional external grants or building the case that the program provides sufficient value to justify being covered by one or more of the partnering organizations.
  • Consider expanding program to other health issues: Once partnerships with community-based organizations are in place, look for additional opportunities for community health workers to enhance medical care by leveraging the existing program infrastructure and model.
  • Promote internally: Giving community health workers opportunities for promotion increases the likelihood they will stay with the organization over the long term. For example, community health workers who work for WIN for Asthma can be promoted to senior community health workers who mentor and train new hires, and/or to a management position supervising other community health workers.
  • Integrate to system delivery: As NewYork–Presbyterian worked to establish patient-centered medical homes with National Committee for Quality Assurance recognition, the WIN for Asthma community health workers were integrated into the NewYork–Presbyterian ambulatory care practices to deliver practice-based asthma support and education. To date, they have served more than 1,000 patients in the ambulatory setting and have become valued members of the health care team. (Updated November 2013.)

More Information

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Contact the Innovator

Patricia J. Peretz, MPH
Manager, Community Health and Evaluation
NewYork–Presbyterian Hospital
622 W. 168 Street, VC4-402
New York, NY 10032
(212) 305-4065
E-mail: pap9046@nyp.org

Adriana Matiz, MD
Medical Director, WIN for Asthma
NewYork–Presbyterian Hospital
622 W. 168 Street, VC4-417
New York, NY 10032
(212) 342-1917
E-mail: lam2048@columbia.edu

Innovator Disclosures

Ms. Peretz and Dr. Matiz reported having no financial interests or business/professional affiliations relevant to the work described in the profile, other than the external funder listed in the Funding Sources section.

References/Related Articles

Peretz PJ, Matiz LA, Findley S, et al. Community health workers as drivers of a successful community-based disease management initiative. Am J Public Health. 2012;102:1443-6. [PubMed]

Footnotes

1 American Academy of Allergy, Asthma, and Immunology. Asthma Statistics. 1996-2011. Available at: http://www.aaaai.org/media/statistics/asthma-statistics.asp.
2 Centers for Disease Control and Prevention. Summary Health Statistics for U.S. Children: National Health Interview Survey, 2010. Available at: http://www.cdc.gov/nchs/data/series/sr_10/sr10_250.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).
3 Newacheck PW, Halfon N. Prevalence, impact and trends in childhood disability due to asthma. Arch Pediatr Adolesc Med. 2000;154(3):287-93. [PubMed] Available at: http://archpedi.ama-assn.org/cgi/reprint/154/3/287.pdf.
4 Kattan M, Stearns SC, Crain EF, et al. Cost-effectiveness of a home-based environmental intervention for inner-city children with asthma. J Allergy Clin Immunol. 2005;116(5):1058-63. [PubMed]
5 Centers for Disease Control and Prevention. Summary Health Statistics for U.S. Children: National Health Interview Survey, 2007. Available at: http://www.cdc.gov/nchs/data/series/sr_10/sr10_239.pdf.
6 Rosenstreich DL, Eggleston P, Kattan M, et al. The role of cockroach allergy and exposure to cockroach allergen in causing morbidity among inner-city children with asthma. N Engl J Med. 1997;336(19):1356-63. [PubMed]
7 New York State Department of Health. Asthma emergency department visit rate per 10,000 population. Available at: http://www.health.ny.gov/statistics/ny_asthma/ed/zipcode/new_y_t2.htm.
8 Hamilton RG. Assessment of indoor allergen exposure. Curr Allergy Asthma Rep. 2005;5(5):394-401. [PubMed]
9 Thyne SM, Rising JP, Legion V, et al. The Yes We Can Urban Asthma Partnership: a medical/social model for childhood asthma management. J Asthma. 2006 Nov;43(9):667-73. [PubMed]
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Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: December 19, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: January 15, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: November 19, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.