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Managing Asthma Triggers at Home: A collaborative effort

State: OH Type: Model Practice Year: 2021

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Summit County Public Health
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Managing Asthma Triggers at Home: A collaborative effort

Summit County Public Health (SCPH), www.scph.org, is a local health department located in Akron, Ohio. SCPH provides a multitude of clinical, environmental and community health services to the residents of Summit County to protect and promote the health of the entire community. One of the programs provided by SCPH includes the Akron Regional Air Quality Management District (ARAQMD), the local air agency covering Summit, Medina and Portage Counties. ARAQMD is contracted to the Ohio EPA to do air pollution regulation, but being a part of SCPH, ARAQMD is able to expand duties to affect other public health issues. One of those expansions is the indoor air quality program. Offering consultation and educational services to the public about the indoor environment to thousands of people since its inception in 1993, the indoor air program has been a benefit to those who contact us.

This three county region has a 2019 population of 883,225 according to the US Census Bureau. The population of the area is primarily Caucasian (84%) and secondarily African-American (10%). In this region, 20.6% of the population is under the age of 18.

Nationally, asthma has been identified as a health disparity for African-American children as 12.7% of that community are affected by asthma, as compared to 8% of Caucasian children (Forno, 2012). This effect has been identified in Ohio as well. Ohio Department of Health states that asthma-related visits to hospital emergency departments are 4 times higher and asthma-related hospital admissions are 5 times higher among black children than white children” (ODH, 2018).

The 2016 Akron Children's Hospital (ACH) Community Health Needs Assessment has asthma identified as a significant health issue by focus group participants in Summit and Wayne Counties as well as by the Akron Children's Hospital Internal team of medical leaders and hospital administrators” (Akron Children's Hospital, 2016). Childhood asthma was also identified as a significant issue by SCPH in the 2017 Community Health Improvement Plan and the creation of a plan to reduce the burden of childhood asthma through community level interventions was proposed (SCPH, 2017). In their 2019 report, the Asthma and Allergy Foundation of America identified the Akron area as the 14th worst place in America to live for those with asthma (AAFA, 2019).

In 2017, SCPH began training ACH Community Health Workers to identify asthma triggers in the home. This training used materials that targeted the housing stock and issues found here in the region and was provided to 30 CHWs. The CHWs were able to use this training to identify environmental triggers and hazards in the homes of their clients. However, in early 2018, the Akron area lost a small child to asthma. It was decided that a more robust program should be created and implemented to help children with high risk asthma to reduce their need for hospitalization and emergency room utilization.

In 2018, SCPH partnered with ACH to create the Managing Asthma Triggers at Home (MATH) program. This collaborative program recognizes that children with high risk asthma can suffer an acute attack, go to the hospital, get the necessary medical attention to address their needs, be released to go home and get triggered again. ACH has an established high risk asthma list of roughly 3,000 children between the ages of 2 and 18 years old. To be included on the list, the child had to have been intubated once, hospitalized twice, or been to the emergency department for asthma in the last 12 months. These are the children we wanted to address in the MATH program.

While ACH gets these patients stabilized while at the hospital, when they are sent home, there are environmental triggers in the home that can re-ignite the asthma flare up and send the child back to the hospital. SCPH has trained staff that can go into the home and identify those triggers and educate the family to reduce the child's exposure to them. With the MATH program, SCPH also provided a suite of intervention equipment to help reduce exposures to environmental triggers. Research shows that individually education, trigger reduction and medical treatment will provide improvements in asthma incidents, a combination of all three will be best. (Cook, 2017, GHHI, 2019)

The goal of the MATH program was to create a pilot project to validate the research (Leas, 2018, Pakhale 2011, Cook, 2017) which said that the combination of the intervention equipment for trigger reduction, education and medical treatment would benefit the clients in a synergistic manner. Secondary goals of the program were to cement relationships between the hospital, the health department and the local metropolitan housing authority to better serve children suffering with asthma and also to begin working with insurance companies to begin covering the expense of the trigger reducing equipment. The collaborative decided that a cohort of 50 clients would be a manageable size for each year, and that the hospitalization usage would be tracked for the year prior to, during and following engagement in the program. Quarterly home visits and Asthma Control Test (ACT) scores were also tracked during the one year of engagement.

Over the first year, the program enrolled 50 clients and tracked ACT scores, emergency room visits due to asthma and hospitalizations due to asthma. It was determined that a second year of data would be useful, so the program was extended into a second cohort. The results were positive, showing a decline in emergency room visits and hospitalizations, an increase in ACT scores and anecdotal evidence showing that the program was beneficial to the families. During the second year, SCPH and ACH began work with the Akron Metropolitan Housing Authority (AMHA) focusing on their asthmatic clientele. SCPH also began discussions with Medicaid payers who have MATH clients about creating sustainable funding for the program.

The success of the collaboration was due to the universal acknowledgement of asthma as an important public health issue, the desire of the partners to assist these clients in improving their lives and the availability of funding to make the program possible.

The region for the pilot project was designed to be Summit, Medina and Portage Counties in Northeastern Ohio, as the funding used was collected from that area for special projects related to air pollution and its effects. ACH serves a region that encompasses 25 counties, including Summit, Medina and Portage Counties. They provide acute, specialty and primary care for approximately 29,000 patients and roughly 10,000 of those are in Summit County alone. A subset of these patients are the target population for this program. If a child has been diagnosed by their pulmonologist as having High Risk Asthma (HRA) that is not controlled, the patient is included on the HRA registry at ACH. These patients are closely monitored as they have the highest likelihood of negative health outcomes. To be included on the HRA registry, they must be under 18 years of age and have been either intubated, admitted to the PICU in the last two years, hospitalized twice in the past two years, or seen in the Emergency Department three times in the past year. The HRA registry is fluid, in that the patients on it can be removed from the registry for improved health, age or other factors or they can be added by meeting the requirements listed above.

The MATH program staff was provided a copy of the HRA registry and worked with ACH's Pulmonology clinic to set up application interviews. Of the roughly 300 children on the registry, the MATH program was able to enroll 88 into the two cohorts. The enrollment was severely impacted by the COVID-19 pandemic, as there was a decline in hospital utilization and restrictions on hospital access to those not there for appointments. At the start of the program, first contact was attempted by phone call to the parent of the patient. This approach was not the most effective, as it was determined afterward that the families did not trust that there were no catches to participation from a cold call from the health department. A quick modification to the program was that the initial contact with the family was done at an appointment at ACH. The doctor was able to initiate the discussion with the family about the program, and make introductions to the SCPH MATH staff in the waiting area. That gave the family a better feeling of connection and trust in the program. Once we enrolled the clients into the MATH program, the SCPH representatives and the families built a bond of trust and that familiarization. The understanding that ACH and SCPH were working with them to better their child's life encouraged the continued participation in the program.

A review of publications and research including the Guide to Community Preventative Services (Leas, 2018, Guide…”, 2020) showed that a combined approach using environmental trigger reductions, education of the family and proper use of medicines provides the best outcomes. (Cook, 2017, GHHI, 2019) The MATH program provides the family with a suite of trigger reduction equipment; bed and pillow bags, a HEPA air cleaner unit, a HEPA vacuum cleaner, a dehumidifier, quarterly replacement filters for the furnace, and annual vacuum and HEPA unit filter replacements. The program also provides the family with devices and tactics to have better adherence to pharmaceutical interventions; an initial home professional deep cleaning, pest control if needed, quarterly text messages with informational content and an extra valved holding chamber, also called a spacer” for the inhaler medicine. The final equipment provided that is not related to asthma, but is vital for safety, is a carbon monoxide detector. In addition to providing the equipment, the MATH program also provides replacement supplies for the year after engagement, such as; vacuum HEPA filters, HEPA air unit filters, furnace filters and batteries for the CO detector. 

According to the Community Guide (Guide…”, 2020), other issues such as home lead hazards, smoking in the home and coordination with schools are also beneficial to help improve outcomes. Another program SCPH offers to the community is the Home Lead-Based Paint Hazard grant. SCPH received an award of over $5 million to address lead hazards in homes in Summit County in 2019. One of the MATH team members is licensed to perform lead risk assessments and uses those skills in every home that the clients reside in. If the home owner is eligible, they are provided the grant application materials and assisted in the process. SCPH also has a smoking cessation program in place through funding from the Ohio Department of Health (ODH). The MATH program refers the client's family members to the program as needed. In 2018, ACH received a grant to increase asthma awareness and medicinal adherence in schools. Their school health nurses and nurse educators are available to school systems in the region.

The referrals and partnerships with outside programs allows the MATH program to offer wraparound services, using established best practices acknowledged by the literature, to the clients and their families to help reduce the impact asthma has on their lives. By addressing lead poisoning, smoking and medical adherence in schools, the entire family is positively impacted by participation in the MATH program.

The goals of the program are to focus on all children with high risk asthma, regardless of race or income. This program is geared only towards those who are in the most need, as defined by severity of illness and its effects. The program is only available to those who live in the service area, are on the HRA registry at ACH, and are willing to participate.

Asthma doesn't just affect the child who is afflicted. The effects range out to the entire family. While the child can have negative impacts due to the difficulty breathing, their ability to learn is impacted by the loss of sleep trying to breathe, the loss of time in classroom and potential damage physically from the asthma. The parents also have negative impacts in losses of time at work to care for the child, losses of potential job promotions or lack of focus at work due to lost sleep. In addition to potential loss, or reduction of income, there are also costs for hospitalizations or emergency medicine required to treat the child. The disease has so many ranging impacts, that it is very difficult to account for them all.

Future goals of the program involve coordinating with Medicaid payers to cover the costs of the equipment which will assist those who may be in financial need as well. While the program serves anyone who is in need, regardless of race, ethnic background or financial situation, the majority of the clients served have been African American (66%), with 25% Caucasian and 9% mixed race children as the remainder. 38% of the homes that the MATH clients live in are subsidized in some way. The other 62% are privately owned or rented by the client's family.

While this program is not entirely novel in its provision of services to children with asthma, the combination of partners and the targeting of those who are most in need is. As identified from reviewing these types of programs, one identified hole in the research is that not many programs use a multitude of approaches to address the asthmatic child's disease and home environment. Other programs have been aimed at the general population of asthmatic children, those who are living in a smaller targeted area, or only use one method of intervention. The MATH program uses a combination of documented best practice intervention equipment, collaboration among diverse partners using each partner's specialty, and specialized education about varied topics. Leveraging the housing authorities' knowledge about their residents and properties, the hospital's knowledge of their patient lists and the health department's knowledge about environmental and residential management to reduce the exposure to the triggers of asthma is where the MATH program shines.

The primary goals of the MATH program were to assist children with severe and uncontrolled asthma in our community, to engage local entities in working towards that end, and to create sustainable pathways to fund this project into the future. The program was designed to identify those children who had shown the greatest need for medical attention and focus the environmental lens on their home situation. By tying the environmental and medical fields together, using the evidence-based methods listed above, the children's asthma should be better controlled and their health outcomes should be improved.

As described above, SCPH and ACH formed a collaborative effort in 2017 to assist children with asthma. This led to a program to better educate the community health workers (CHWs) who went to the homes of ACH's asthmatic patients to identify and reduce the interaction with asthma triggers. As there were a limited number of CHWs working with the asthmatic clients, this wasn't the most efficient method of providing service to the clients. While this project was productive, albeit not to the levels that either side of the collaboration was expecting, the partnership was deemed successful and alternative methods of moving the project along were discussed. ACH invited SCPH to be a part of their internal asthma steering committee and the team leads meetings The Asthma Steering Committee is comprised of individuals from the Quality Improvement Team, Pediatric Pulmonology and Allergies Departments, hospital administration and SCPH. The Steering Committee's goals are to reduce hospitalizations and emergency room usage for asthmatics by a defined amount and also to reduce readmissions for asthma episodes. The Team Leads convene bi-monthly to discuss how the various departments in the hospital can coordinate efforts to change the service provision from a silo approach to one where wrap-around services are the norm. SCPH was invited to be a partner in these to incorporate the ACH-SCPH partnership, and the MATH program, into the discussions.

During the course of the MATH program's interaction with clients, it became clear that a significant portion of the MATH clients lived in subsidized housing. Over one-third of the clients live in housing owned by, or subsidized by, the local metropolitan housing authority. The Akron Metropolitan Housing Authority (AMHA), has over 4000 apartments and single family homes, and provides subsidized housing to thousands more in the Akron area. The relationship between AMHA and SCPH grew from work being done on an SCPH initiative to reduce lead hazards in the home and the drafting of a new lead code for the residents of Summit County. This work began in 2018 with the lead code being passed in December 2019.

The collaborative effort between SCPH and ACH began in 2017 with the CHW trainings. The program redesign to the MATH program began in 2018, with implementation in the summer of 2018. The goal was to recruit 50 clients in the first year (July 2018-June 2019) and follow their hospital usage for the year prior to engagement, during interaction and afterwards for a total of three years of data. As we got the first cohort of clients in the program, we determined that funding and workload could accommodate another cohort over a second year of the program (July 2019-June 2020). The goal is to have the entirety of the two cohorts completed by June 2021 and final data analysis can occur to determine how well the interventions, medical attention and education worked to help improve the lives of the clients. SCPH and ACH have worked diligently to ensure the safety of the clients and promoting the healthy behavior to improve the future of our clients. The data set included inpatient admissions and emergency department visits for asthma issues for the year prior to our engagement with the client, the year of interaction once the intervention had occurred and the year after we disengaged with the family. The working hypothesis

The initial programmatic design began in 2017 at SCPH with the design of the CHW training protocol. Almost 30 CHWs were trained on environmental triggers in the asthmatic patient's home over the summer of 2017. When the decision was made to expand services to those more at risk, rather than just those with asthma, the true collaborative effort began. ACH accepted SCPH onto their internal steering committees and we have a say in the direction of the hospital's non-medical asthma care programming. SCPH partnered with ACH and the Akron Public Schools (APS) to get school nurses to help children better adhere to their asthma plans.

The program's costs are entirely for supplies and staff time. Some of the time is donated as in-kind assistance from ACH and SCPH and the remainder is paid through funding sources at SCPH. The supplies are purchased through the funding at SCPH. There were no startup costs, as the time associated with the program's development was donated by both partners.

As the program is still actively engaging with the clients, the costs are not yet complete, nor are the results of the data analysis. From the initiation of the design of the program in January 2017 through December 2020, the actual costs were as follows:

Equipment/Supplies:                                      $132,465

Services (pest control or cleaning):                 $19,847

Salary/Benefits:                                               $252,753

In-kind salary/benefits were not tracked for this program, but there are an estimated 200 hours of work hours donated by ACH to facilitate this program for data collection.  With an estimate of $75/hour for the ACH staff's salary/benefits, that is another $15,000.

The results from the MATH program thus far will be discussed in the next section.

Other directions taken were to involve AMHA in the program in 2019 and reaching out to Medicaid payers to discuss them covering the equipment costs and partnering with SCPH/ACH to continue this program into the future. During analysis of the clients, it was identified that a large portion of them have assistance from Medicaid paying at least a portion of their medical costs. 38% of the MATH clients live in subsidized housing, most in single family structures owned by individuals and rented through Section 8 funding or an alternate subsidization mechanism. AMHA owns a large number of properties but the majority of the children in the MATH program are not living in those. They live in the privately owned properties that are subsidized by AMHA or HUD funds. It was determined through data analysis that there was a need for SCPH to work with AMHA to train their inspectors on asthma triggers in the home, so that these children living in subsidized privately-owned housing rentals could be protected from those triggers. AMHA works closely with Medicaid payers as well, and through this network, SCPH was able to get into discussions with two payers. These discussions are in very early stages at this point, but the goal is to get them into the partnership with SCPH, ACH and AMHA to protect these children who need the assistance the most.  

Active evaluation is a major component of any project. As many sources provided primary data for the project, and several types of data were collected, combined and analyzed, it was imperative to keep an active eye on the data to ensure that all data was collected properly. As some of this data is a snapshot in time of the client's self-assessment of their well-being, if that data point gets missed, it is impossible to go back and collect it. The MATH program was evaluated in two methods: process evaluation, which are evaluation steps taken as the project is active, and outcome evaluation, which looks at the results of the program. As the program is part of a collaborative effort, quarterly meetings were held and the program results were presented to the team for discussion. Through these discussions, many modifications were initiated and then implemented. The MATH program was approved by the ACH Institutional Research Board (IRB) prior to commencement, so substantive changes to the program would have required an amendment approval from the IRB. Also, to keep this program data as consistent as possible, no major changes were made to the IRB approved protocol. The patient's (or parent's) assent was obtained, home visits scheduled and completed, ACT was completed at the initial visit, and the equipment was delivered. After that, the quarterly visits were completed with an ACT and any replacement supplies were delivered. Asthma specific educational text messages were sent to the family monthly to keep them engaged and build a relationship.

From the initial step of consenting the family to enroll them, we quickly identified that the biggest hurdle we had, was building trust between the family and SCPH. The family had an existing relationship with ACH and trusted ACH with the care and wellbeing of their child. At the outset, SCPH was provided a list of the HRA patients and calls were placed to the families. There was little desire from the families to participate due to the current state of skepticism surrounding cold calls from organizations offering free services/equipment/etc. We discussed this issue at a Steering Committee meeting and ACH allowed SCPH access to the patients at the end of their Asthma Clinic visits. If the patient were a good candidate for the MATH program, they were informed of the program by their doctor and an SCPH representative was in the waiting room to discuss details and enroll them into the program. This modification was minor, but garnered huge results.

Another process evaluation and modification made in response was that in early 2020, the COVID pandemic struck our area and SCPH began the process of refocusing to COVID response. We continued the MATH program with modifications to protect our clients. As the clients are enrolled in the MATH program, they are already at the highest risk for negative health outcomes if they contract COVID. Due to this, we began doing the quarterly ACTs from the driveway on the phone and delivering equipment/supplies on the porch, rather than having that in person contact. As the ultimate goal of the MATH program is to help these high risk patients, it seemed anathema to put them at risk of contracting COVID through unnecessary interactions. As hospitals were becoming more and more concerned about COVID, they shut down unnecessary visitors in April. Because of this, SCPH staff couldn't access the clients for recruitment into the program. After deliberation, both internal and external with the partners, the recruitment for cohort two was cut off at 44 instead of the full 50.

As SCPH staff members made the quarterly home visits, ACT scores were collected and environmental assessments were done at the home and to document any potential new asthma triggers (i.e.; did the family get a pet during the last few months or was there a deterioration of the home). ACH data analysts provided data about the client's hospitalization and emergency room visits quarterly from their medical records. Costs for equipment and staff time were tracked quarterly by SCPH to provide a true cost for the program.  Both process evaluation and outcome evaluation were done during the program. The equipment suite was kept static throughout the course of the two cohorts to ensure that there was continuity. There was discussion about modifying the brands of equipment, but not the types, to lower the costs of the program, but it was determined that since this was being done to show the potential cost-savings to the payers, changing the equipment mid-stream was not desirable.  The data was reviewed prior to analysis for completeness and any anomalies were removed as applicable. Those anomalous values were maintained in the complete record and the reasons were noted.

The data for the first cohort of 50 clients is still being collected, but preliminary analysis looks very positive. ACT scores have increased by a significant amount (Schatz, 2009). The ACT score is a self-assessment of the child's reaction to the control of their asthma over the past several days. There are a lot of variables that can affect their score, but this gets factored into our analysis. The ACT was analyzed by time in program (first through fourth interaction) as well as quarter of the year, knowing that there are seasonal allergies in the spring and flu/cold season in the fall/winter. There has been a seasonal influence on the ACTs, with dips seen in spring and fall.

For the initial cohort of clients, the average ACT score was 18.3 at the beginning and ended up at 22.7. According to Schatz et al. (2009), the minimally important difference of the ACT is 3 units. For the second cohort of clients, the average ACT score was 19.3 at the beginning of the program and 21.3 at the end of the program, but this data set is very incomplete. Only nine of the second cohort have completed the full four ACTs.

The inpatient (IP) hospitalizations and emergency department (ED) visits have also declined precipitously over the time frame of the study. The table below shows the first and second cohorts IP and ED usage:

 

                       Before MATH (ED/IP)      During MATH (ED/IP)    After MATH (ED/IP)

Cohort 1                   37/38                                33/20                              29/7

Cohort 2                   14/18                                 24/8                                4/0

Total                          51/56                                57/28                              33/7

As described above, the second cohort has not completed the cycle, so the 'after MATH' numbers are biased extremely low. That being said, with the assumption of a $5,000 per IP and $1,000 per ED cost, the total for cohort one's hospital usage has declined from $227,000 pre-MATH to $133,000 during MATH to $54,000 after-MATH. That is a drop of almost 75% in estimated medical costs to whomever is paying.

As described above, the costs for hospital utilization of the first cohort of MATH clients has been demonstrated to decrease by approximately 75%, or an estimated $175,000 from the year before engagement to the year after, for the equipment cost of roughly $75,000 (salary/benefit notwithstanding). This translates to a cost-benefit ratio of almost 1:3. These equipment costs are borne by SCPH and the staffing costs are paid for by SCPH and ACH. The actual cost savings are to whoever pays the bills, which for almost all of the MATH program's clients, is one of the local Medicaid HMOs. Through the inclusion of AMHA in the partnership, a link to the HMOs was established. With this connection, initial meetings have begun to engage the payers and show the data that has been generated with potential cost savings.

The collaboration between ACH and SCPH has proven to be very fruitful, with the effort assisting almost 100 of their most at-risk patients to learn how to protect themselves from the negative outcomes of asthma so that the children and families can have improvements in their lives. The work being done has led to other vital partners in our community that is helping the collaboration to expand services to others. It is the hope of the team that this may be a program that assists not only those with severe uncontrolled asthma, but those with lesser severities across the board. Imagining a world where asthma trigger reducing equipment can be provided by insurance or Medicaid payers, similar to crutches for a broken leg, to anyone who is in need of them is astounding. The ability to provide environmental education and dedicating the time to interact with our citizenry is one of the foundations of Public Health and is something that we have always done and will continue to do. The ability to take in, treat and heal the sick is the basis of the hospital systems and is something they have always done and will continue to do. The ability to provide housing to those who are financially less fortunate is what the housing authorities do. Each of the partners have a specialty that touches on the client's lives in a significant way. By putting our heads together, sitting at the same table and having the significant discussions about how to best help children with severe uncontrolled asthma, while each staying in our own specialties, we have created a synergistic program that has the ability to help improve the lives of the clients and their families.

Through meetings and discussions over the last half of 2020, there is a strong desire by all partner entities to continue the MATH program and possible expansions or modifications to give the same or better services to those in need. The program is directly tied to each organizations missions and goals and the momentum is in place to continue the program into the future. The biggest portion to figure out is the funding. SCPH has funding to keep the program going for another two or three years without modifications, longer with equipment substitutions for similar effect, but lower cost. Research has shown us that we can get similar functioning equipment for much less money. We made the decision, after much consideration and discussion, to provide the exact same suite of intervention equipment throughout both cohorts. The cost for the whole suite was roughly $1,200 per client. Currently, we have found similar performing equipment for the entire suite that is more in the $500 per client range. The Asthma and Allergy Foundation of America (https://www.aafa.org/certified-asthma-allergy-friendly/) has begun publishing lists of asthma approved trigger reducing equipment. Use of those lists will allow us to provide suitable equipment while reducing costs for the program. These lists will also be useful in the discussions with payers, as they can identify their costs to be balanced against their savings in medical care costs.

At the end of the day, this project has allowed the health department, the hospital, the housing authority and the Medicaid payers to be at the same table, discussing how best to provide wrap-around care for children in our community stricken with severe uncontrolled asthma. This program helps the partners improve the lives of the families and outcomes of the children involved and may allow for children with uncontrolled severe asthma outside of our region to be positively impacted as well.