National Models for Asthma

By Adem Lewis / in , , /

Tracey Mitchell: Hello and welcome. And thank
you for joining us today for our webinar, National Models of Asthma Care: Best Practices
from the 2019 Asthma Award Winners. This is a web-based presentation sponsored by the
U.S. Environmental Protection Agency. My name is Tracey Mitchell, and I’m a registered
Respiratory Therapist and Certified Asthma Educator in the Indoor Environments Division
of the U.S. Environmental Protection Agency in Washington, D.C., and it is my pleasure
to join you today as your facilitator for today’s webinar. I’m excited to introduce
you to EPA 2019 Asthma Award Winners. Today, we have with us Mobile Care Foundation, Mobile
Care Chicago Asthma Van. This is a unique program a unique mobile program providing
health care throughout the city of Chicago. Our second winner is Omaha Healthy Kids Alliance:
Asthma in Home Response Program. This is a community-based asthma program reaching disproportionately
affected children with asthma in Omaha. And our third winner is the Rhode Island Department
of Health Asthma Control Program, Home Asthma Response Program, or HARP. This is the state
health department who’s been expanding their services throughout the state of Rhode Island.
So, there you can see the teams. We have representatives from each program here today to share their
experience and their award-winning successes with you. Now that we know a little bit about
our speakers and we’ll hear more about them in a minute I’d like to hear who’s in
our audience today. So, if you would please answer our first polling question: what type
of organization do you represent? Please click on the answer that best describes the organization,
whether it’s government agency, health care provider, health plan, community-based program
or other. Great, so about a third represent a government agency. We’ve got about a quarter
that describe yourselves as “other,” so that’s interesting, but we’ve got good
representation from community-based programs and health care providers and even a few health
plans. This is great. These are the audiences that represent comprehensive…the best in
comprehensive asthma care, and I’m confident that no matter what organization you represent,
you’ll take away something from our speakers today that will help your asthma program.
So speaking of our take-aways, what are we all about today and what are our learning
objectives? Today, participants will hear successful strategies from the winners of
the 2019 award successful strategies for addressing asthma triggers, for engaging community health
workers and for pursuing program sustainability and you’ll also learn how building partnerships
with community organizations, including local school districts, strengthens community ties
and improves comprehensive care. You’ll understand how to effectively track data to
measure key program outcomes and cost savings, and you’ll hear how these programs have
done that. And you’ll also discover strategies for pursuing reimbursement through Medicaid
and some health plans to help insure the full continuum of care and to help with program
sustainability. Just like to take a couple moments to talk about EPA’s awards program.
The awards program is one component of EPA’s overall asthma program, and through this award
we are aimed at surfacing success and highlighting success in asthma care to enable to more rapidly
spread adoption of best practices across the country. The National Environmental Leadership
Award in Asthma Management is the highest recognition in the country. It’s the highest
recognition a program can receive for delivering excellent asthma care. It’s particularly
environmental management as part of comprehensive care. Through a competitive process, which
includes that consensus panel of asthma experts across specialties, including Federal agencies
other Federal agencies like CDC, HUD, and NIH and nonprofit organizations, including
the American Health Insurance plans and the Allergy and Asthma Network, and the previous
winner and this year, it was Impact DC out of National Children’s Medical Center, and
so this consensus panel these experts judge the applications against the published criteria
in order to choose the best of the best. Winners received national recognition to a press release,
blogs, and other social media and are featured on the national webinar like we’re doing
today. Winners also receive a crystal award and an opportunity to serve as mentors to
other programs throughout the country to help them achieve impactful results. Winners also
receive a place on hall of fame. Today’s winners joined 43
other health plans, health care providers and Communities in Action who have been recognized
over the past 15 years or so for their best practices and best successful approaches to
delivering comprehensive asthma care. I invite you all to at some point visit
and hall of fame to learn more about all of our previous award winners. I think if you’re
joining us today, you know why this work is so important. You know about why asthma is
such an important health issue, and you’ll hear local statistics from each of our winners,
but we know that nationally, asthma remains a public health challenge, characterized by
disparities. We’ve made progress to decrease asthma prevalence, yet there is still a critical
need for solutions focused at the state and community levels to address out-of-control
asthma, which we know would be to increase costs. There is some good news; CDC reports
that some national indicators are improving. Asthma prevalence among children has decreased
slightly, and we know that between 2003 and 2013, asthma-related hospitalizations and
missed school days actually decreased. Yet, important health disparities continue. Children
living below the poverty line experience the most emergency department visits, missed school
days and hospitalization. These high utilizers with uncontrolled asthma drive up the cost
to over $50 billion each year, but the good news is we know how to treat and manage asthma.
Science informs policy and forms the foundation of EPA’s Asthma Program, and science tells
us that along with medical management, there’s strong evidence base and supporting National
Guidelines that recognize the role of environmental triggers and their remediation as an important
part of comprehensive asthma management. We know that eliminating common indoor triggers
like tobacco, smoke, pet dander, mold, cockroaches and dust mites results in decreased symptoms
in asthma episodes and improves health outcomes for people with asthma. We also know that
home visits are a critical care component that we need to address particularly for at-risk
populations. Home visits provide one-on-one time for families and helps them to figure
out tailored approaches to addressing asthma triggers and to ultimately help control their
child’s asthma. As technical experts in the built environment and health, EPA has
lead the Federal effort to nonregulatory strategies that enable communities to deliver and sustain
in-home environmental asthma care aimed at ensuring access. And so, ultimately, EPA supports
widespread delivery of in-home environmental interventions, because it reduces health care
costs, increases savings and expands health care workforce. EPA also developed a system
for delivering high-quality asthma care, which features essential components to developing
an effective and sustainable asthma program. The system you see on the screen is a conceptual
framework based on results of the Asthma Health Outcomes Project conducted by the University
of Michigan several years ago. This project identifies the core elements of successful
asthma programs and the processes that drive their implementation, continuous improvement
and endurance. The five key drivers you see highlighted in the circles in the middle of
the screen are our committed leaders and champions, strong community ties, integrated health care
services, tailored environmental interventions, and high-performing collaboration. Just like
to offer a second polling question at this point, based on those five key drivers that
I just described and they are listed there for you please select which of the following
best practices or key drivers you’re currently employing in your work, and you can choose
all that apply to your program. Oh great. This is very exciting. So over half of you
are strongly connected to your community. Over half of you are providing integrated
services. Almost half are providing tailored environmental interventions. Many of you have
high-performing collaborations and committed leadership champions. So that’s great. There’s
always room for improvement, right ? There’s at least 50 percent of you in each one of
those categories that can learn something today and will learn something today. So I
said today’s award-winning programs exemplify all of the key drivers that we talked about,
and then I invite you to be listening for how these program components show up in unique
and different ways in each program. And so now, I’m excited to introduce our first
speakers from Mobile Care Chicago. We’ll be hearing from Matt Siemer. Matt is the Executive
Director of Mobile Care Chicago. Matt has a Master’s degree of Arts of philosophy
from Duke University, and he joined Mobile Care Chicago in 2012 and assumed the position
of Executive Director in 2016. Joining Matt is Amy Bain. Amy has her B.S.N. from Indiana
University and completed her Master’s degree in nursing at Rush University. She’s been
a pediatric nurse for 14 years and a pediatric nurse practitioner for nine of those years,
and Amy joined Mobile Care Chicago in 2012. Welcome, Matt and Amy. Matt Siemer: Thank you, Tracey, and yeah,
thank you to the EPA for this honor and for allowing us to be participating in this webinar.
And yeah, today I’m going to talk about Mobile Care Chicago in a couple of different
ways, just sort of how our program got started in the way that we’ve grown our program
over time to innovate in two different models of care for kids who have severe asthma. And
then Amy is also going to talk specifically about our clinical model and how we sort of
stage our interventions. Okay, so Mobile Care was founded in 1999 by four physicians, but
primarily by Dr. Phil Sheridan, who was a chest surgeon, and his son is a pulmonologist.
His son-in-law is an allergist, and so he was heavily involved in lung health at the
time and went out to Los Angeles and visited the BreathMobile out there, which was the
first one in the country founded in 1994, and really liked that model. The basis of
what we do still comes from a foundation of a BreathMobile model, and then we’ve just
sort of adapted it to our needs here in Chicago. All right. We have two asthma vans currently.
They rotate through 47 different partner school sites. We do a little over 2,700 patient visits
per year, and our program is more about follow-up care about 85 percent of what we do is follow-up
visits, and it’s very labor intensive, so we expect to see all of our patients three
times a year on average, and most kids stay with their asthma vans for 7 years right now.
A lot of what we do is seeing the same kids a lot. In 2013, we really got into the home
environment assessments, and we started working with an emergency department here in the city
of Chicago that had a lot of pediatric cases of asthma. And working with them and using
a community health worker model, we were able to reduce emergency department visits for
pediatric cases in that particular hospital by 84 percent; that was over a 3-year period
and was really the driver behind what we do now, which is an integrated approach and all
of the neighborhoods that we go into. And as I said, so our asthma vans for our core
program our sort of flagship program: We have two of those that rotate through the city
of Chicago and into the collar suburbs. We have dental van, a portable dental clinic
that is a pop-up clinic it can be set up inside a school and then we also do our home assessment
programs through our department of patient services, and so, they really manage all of
the most severe cases of asthma that we see. I wanted to step back just a little bit and
talk about why in Chicago this particular model made sense, especially over a 20-year
period. There’s been a lot of research in Chicago about the number of kids who have
asthma and where they’re concentrated, so in a lot of our low-income areas, over 25
percent of kids have asthma. In one neighborhood in particular, 33 percent of kids have asthma
based on the latest research. It’s the number one cause of pediatric ED visits here in the
city and also the number one cause of school absenteeism according to Chicago Public Schools.
And alarmingly, so when Mobile Care first started asthma, we were the number one city
in the country for asthma fatalities. We’ve now been demoted to number two. I would prefer
that we not make the top 10 on that list. We still have a lot of work to do, but that’s
one of the drivers for why this program remains so important and why we continue to adapt
it into these communities. All right, so now I’m going to move…transition it over to
Amy to talk about our care practice. Amy Bain: Hi, so this slide is an overview
of our model of care, which I’ll explain in more detail over the next few slides. Our
model of care begins with surveying. The majority of our patients are obtained through surveying
the student body of our participating sites on an annual basis. We provide the sites with
the attached parent handout that ask five questions and states that if they answered
Yes to any of the questions, then their child may have symptoms of asthma and gives the
parent the option of a no-cost evaluation and treatment by checking the box. We provide
services to children ages 6 months to 19 years of age and receive many referrals from existing
patients and primary care providers within the community. Therefore, not all of our patients
that are seen at the various sites are current students at the school. After surveys are
collected, an initial patient visit is scheduled. After brief introduction of our program, the
first appointment is underway. Our bilingual MA collects the medical information from the
parent. She obtains data on life [inaudible] history of emergency room visit, missed school
days, and hospital admission. This information is also obtained in each subsequent visit.
Meanwhile, the driver obtains the vitals, conducts spirometry and FeNO on the patient
and requests the parent or patient to fill out the Asthma Control Test or ACT, and the
provider determines if a post-spirometery is necessary and discusses the diagnostic
results with the parent, as well as the diagnosis determined at the initial visit. The parent
is educated on the triggers and symptoms of asthma, as well as an abbreviated pathophysiology
of asthma. They’re also educated on the difference between a controller and a quick-release
medication, and a handout is given that addresses all this information, as well. An Asthma Action
Plan is also created for the child and reviewed with the parent. The patient and parent practices
using the age-appropriate spacer and other medical devices. A treatment plan is developed
for the patient and reviewed with the parent. We discussed with the parent that a follow-up
appointment in one month with an allergy skin test is recommended. This is one of our patients
performing FeNO. We have had FeNO for about 9 months on both of our asthma vans, and it
has helped with our patient compliance, as they give our patients and their parents a
tangible value for airway inflammation. This is one of our newer patients. His mother actually
saw our van parked in front of one of the schools and knocked on the door and asked
if she could have her son be seen. She was worried about him. At the time, he didn’t
have any health insurance, and she had nowhere else to go, so we took her information and
we called her and we scheduled her for appointments, and he was diagnosed with asthma. In this
picture, we are teaching the mom how to use the [inaudible] with mask correctly. We return
to our model of care that shows that after the initial visit we provide ongoing treatment
and home assessments, then back to re-surveying the following year. We strive to provide continuity
of care on the asthma van with the goal to see patients back within 1 to 2 months of
their initial appointment, and as Matt mentioned, the majority of our patients stay with their
asthma vans for 6 years and more, averaging three follow-up visits per year. We asked
the parents the opportunity of…I’m sorry, the option of physically coming to child’s
appointment or having a virtual visit through either face time or Skype if they’re not
able to miss work or have other obligations where they just have to be physically present
at their appointment. We rolled out virtual visits about a year ago. I had a few pilot
schools, and they are now conducting them at all of our sites. Parents appreciate the
flexibility. We have even been able to see a patient when she was having an asthma exacerbation,
and her mother was in the ICU for kidney failure. At the follow-up visit, it is determined that
the patient is receiving adequate treatment. The appointment is also utilized to review
medication and information and also obtain an allergy skin test. Eighty-five percent
of pediatric asthma is due to allergies. Therefore, we provide allergy skin test physically at
the second clinic visit, testing for the most common allergens in the Chicago area, and
we will repeat testing as needed on an annual basis. At every visit, we review that asthma
action plan and recommend home assessment, if appropriate. This picture is an example
of the extensive treatment performed on the asthma vans. We have two brothers here, the
younger one near the window is receiving an albuterol neb treatment for an asthma exacerbation,
while his brother is receiving an allergy skin test. And here are two more siblings
that we see on the asthma van, and I wanted to share with you the baby story who I will
refer to as “E” So we started seeing E when he was about 10 months old after his
mother learned of our program through her sister whose kids we also see on the van.
We treated his 3-year-old brother; he is standing next to him on the picture. He was born at
36 weeks gestation and started having respiratory difficulties and congestion around 1 month
of age. Prior to coming to the asthma van, he had been taken to the emergency room twice
for respiratory distress and was admitted after each of the emergency room visits. At
4 months of age, he was admitted to the intensive care unit requiring incubation for 3 days,
and he was again admitted to the hospital at 7 months of age for respiratory distress,
where he was admitted overnight for a week. When he came to the asthma van, the mother
stated he had a bad cough, wheezing, daily congestion, and occasional retractions and
respiratory distress. She said that she couldn’t sleep at night due to worrying about her baby
being able to breathe and had him sleeping either in his car seat or on a wedge at all
times. She had mentioned this to her primary care provider but was not referred to a specialist.
After meeting E and his mother, we started him on a daily controller medication and educated
the mother about the medication and his symptoms. She was instructed when to use the medications
and how often. Since his first visit over 2 years ago, he has not required additional
emergency room visits or hospitalization, and now when he gets sick, his symptoms are
well controlled and only last a few days. The mother states that his symptoms have resolved,
and he no longer has wheezing or retraction. The mother says she’s very happy regarding
the services her sons have received and agreed to have her son’s story shared. We conduct
telemedicine calls to follow up on our patients on a regular basis. We have found regular
contact with the patient and families have improved our medication’s and appointment’s
compliance. A community health worker goes into our patients homes to do a thorough assessment;
we’d like this to occur after an allergy skin test has been conducted, so that we are
aware of what the child is allergic to. The CHW is looking for any environmental factors
that can worsen our patient’s asthma symptoms. She provides education and resources for what
she finds during the assessment. Some of the products that are given for our patients and
their parents free of charge include allergy mattress and pillow covers, bed frames, mattresses,
furnace filters, air purifiers, air conditioners, dehumidifiers, green cleaning kit and vacuum
cleaners. So, the photo in the top right corner shows how when this CHW walked into the house,
she found where the boys were sleeping, which was on an air mattress in the middle of the
living room. So, their bedroom was full of clutter, and they didn’t have anywhere to
sleep, and the father said, “I think they had to get rid of their beds.” We’re not
sure why, but we were able to help clear out the clutter in their bedroom and provided
them with new bed frames, mattresses and an air filter, which you can see in the middle
of the bed, and the boys were super excited to now be able to sleep in their own bedroom,
and you can see them there each of the boys there on their bed. They’re trying to ignore
the fact that the dog is on the bed; we did tell them that was not advised.
Matt Siemer: Okay, so, you know, as you can see, a lot of what we do and a lot of the
success of this particular program has to do with just an intensive amount of labor
that happens for, you know, patients who have a lot of ED visits, trips to the ICU, missed
days at school, and might not live in a neighborhood where they have easy access to see a specialist
or even a primary care provider, in some cases. But I’d be remiss if I didn’t also say
that the reason why we’re able to do this work is because we also have strong partnerships
with the American Lung Association, the Chicago Chapter here which is very strong and helped
us cover the costs of the remediation when we do home assessment The University of Illinois
at Chicago, and in particular, their Department of Epidemiology, which has long been a partner
on research grants and helped us get our community health worker program started in 2013. Our
local school site, as I said we have 47 different partner schools and all of them volunteer
in this work and do it willingly, because they see the benefit of it. And then also
the Chicago Asthma Consortium, which is our sort of local group here that promulgates
best practices for asthma and asthma management and also does quite a bit of convening among
the different stakeholders who can affect asthma and can ultimately lead us to change.
I also wanted to point out one of our partners, Perfect Air, who is relatively new. They’ve
been working with us for about a year now. It is a local company that manufactures and
distributes air conditioners and dehumidifiers and gave us a generous donation of quite a
few, including some that we were able to give out to our partner school sites that don’t
have air conditioning. That was one way that we could try to make sure that schools also
know that we care about the air quality in those particular spaces. We obviously recognize
that children spend a lot of time there, and so, this was at Visitation Elementary, which
is one of our school sites, and they seem to pretty happy to get some air conditioners
and some dehumidifiers. We pulled out our data for one full year. This is direct from
our electronic medical record database, and so in aggregate, our baseline for our kids
who were coming through for the first time, you’ll notice that less than half did not
go to an ER in the last year before coming to their asthma van. Nineteen percent had
been hospitalized for asthma, and less than half qualified as well controlled on an ACT.
That’s sort of where we’re at when patients come in. This is where they are a year later.
Those exact same patients, and you can see that you know only 6 percent went back to
an ED, 2 percent went back or were hospitalized, and now three quarters qualify as well controlled.
One of the things that we’ve talked about, in particular, with the EPA is that for every
$3 that spent in prevention or toward the asthma van…I’m sorry, for every dollar
that’s spent, we save $3 in the health system, and these are not data that we put together.
We actually asked the Illinois Department of Public Health to get us some sort of data
just on the savings in ER visits and hospitalizations alone, and this is what they came back with.
I’d just like the end our presentation with Christopher, this particular patient, who
started coming to us when he was an infant, and the reason that I like to talk about his
story is because this is really what we want for every child in our communities. Christopher
has severe asthma, and in his entire time that he’s been coming to the asthma van,
he has not been to the ER. He has not been to the hospital. He misses less than the national
average per days of school. Even though he has a very severe case of asthma, it’s not
affecting his life, and he play sports he plays three different sports and is perfectly
healthy. That’s what we’re really striving for; that’s the goal of this program, is
to try to make sure that we get kids as young as possible, make sure that the diagnosis
is correct, that they put under treatment plan that works, and that they can thrive
in their everyday lives without thinking about this chronic condition. Okay and then just
briefly, this is our summary. We reach about 20,000 families annually through the screenings
that we do for asthma. We have over 100 school partners in mobile care generally this is
including the dental side of our operation and then of course our goal is comprehensive
care for the leading driver of health care costs for children and for school absenteeism.
Thank you again to Tracey and to the EPA for allowing us to share this program in this
particular model, and I look forward to answering any questions if people have them. So, thank
you. Tracey Mitchell: Fabulous, thank you, Matt,
and thank you, Amy. What a great example of strong community ties and high-performing
collaboration and really some impressive return on investment data. So, thank you, thank you,
both. Our next presenter is Ian Sheets from the Omaha Healthy Kids Alliance. Ian is a
native of Omaha, Nebraska. He has been with the asthma in-home response or Project AIR
program for about three and a half years. He is currently pursuing his Master’s degree
in Administration, and again he’s at the Omaha Healthy Kids Alliance, a nonprofit that
focuses on ensuring children’s health through Healthy Homes. So, welcome, Ian. Ian Sheets: Thanks, Tracey. So, like Tracey
said, my name is Ian Sheets. I am the Branch Manager at Omaha Healthy Kids Alliance. We
are a Children’s Environmental Health nonprofit that was started in 2006 out of Omaha’s
Residential Superfund Site. That’s the largest Residential Superfund Site in the nation,
and that Superfund Site was designated by the EPA because of high levels of lead contamination
in the soil. So, Omaha Healthy Kids Alliance was started as sort of the Community Education
Response to that designation, but in 2010, we started realizing that going into houses
with problems with lead We were noticing a lot of other issues that also needed to be
addressed: things like mold, pests, moisture, intrusion, things like that. So, it kind of
pivoted to Holistic Healthy Housing in 2010, but we still do a lot of lead-poisoning prevention
education, but as part of that shift, we really start focusing on indoor air quality. Really,
the focus of our work is, like Tracey said, making sure that kids are living in healthy
homes, so we try to tackle environmental health through the built-in environment. Like I said,
we still do communitywide education on all parts of healthy housing topics through a
lot of different initiatives. But, I am here today to talk to you all about our Asthma
In-home Response Program. We like to call it Project AIR started in 2015 as a partnership
with Kresge Foundation. They were doing a series of pilots across the nation on multicomponent
or as we call, multilayered…multitrigger in home asthma interventions. So, we’re
working with a bunch of other organizations across the country on their programs at the
same time. And ours really got it to hold in the community after that pilot was done,
so we’ve been going strong since then. The components that we focus on are the behaviors
of the family, and those aren’t just reducing negative behaviors, but also increasing positive
behaviors; I’ll go into that in a little bit just basic education about asthma triggers
and asthma medication; supply provisions, so making sure the families have the things
that they need to take care of the triggers inside their house and then also knowing how
to use them; providing free reconstruction to the families, if possible, so getting rid
of things that exacerbate asthma whether that’s fixing an active leak or installing ventilation
systems; and then finally providing referrals and triage care to other organizations, making
sure that families can focus on the other issues that they have that might be out of
our wheelhouse. We serve, it says here about 50 kids a year and that’s really more 50
homes a year is what we’ve been aiming for recently; sometimes we’ll serve a family
that has more than one kid with asthma, so that number there’s a little bit of wiggle
in there. This is just a brief breakdown of the program: first, the family is referred
to us either through word of mouth or an outrage event or a formal partnership. We do a quick
intake just make sure that the family knows what our services are and make sure that we
know as much about the family as we need to before we go into the house. We have an initial
visit, or we provide some education and do an environmental evaluation of the house,
and then later, we come back and drop off supplies. And then later than that, if we
can, we provide construction and do some follow-up visits after the construction is completed.
So kind of a more [inaudible] look at the visit that we conduct initially. It’s a
full-scale environmental assessment, so our inspectors are trained in healthy housing,
indoor air quality–you know measurement of environmental hazards–and they look at everything
for all of our Healthy Home Assessments, as we call them, but for AIR families especially,
we look at the quality of the air and the hazards as they pertain to the kids’ triggers.
And so while we have one inspector doing that assessment of the house, we have another inspector
or staff member conducting education and getting some baseline information about the child’s
asthma. During that, we also provide some pretty simple general information and education
about asthma, some things that the parents might not know; build some rapport with the
client make sure that they know that we’re there to help and that we will be following
up with them pretty regularly; and then we start to establish some potential referrals,
so if it seems like there’s a partner that we have out there that immediately could start
helping the family, we’ll be able to help them and contact them in the field. And then
at the end of that visit, so when the person is done when the staff members are done performing
their assessment and the other staff members are done collecting that baseline information
and providing that education, they both kind of meet in the middle with the family, talk
about the findings of the assessment of the house, as those kind of correlate with the
triggers that the educator established during their questionnaire and then kind of work
with family and talk about next steps and then go back to the office. The next part
of the process is both of those staff members work together on making sure that the supplies
that are provided to the family are appropriate and relevant to the child’s asthma triggers.
So there is a baseline of materials that we do bring to every family, but then if we noticed
that there is a cockroach infestation, we will add some, maybe some Roach Bait and some
education about pest, integrated pest management. We also look at the family’s needs, so if
they need mattress covers, for example, we will make sure that we bring those, bring
furnace filters based on the furnace size, and then also just taking a look at the home’s
health and providing some specific supplies to mitigate any hazards that the home might
be presenting. And then we bring those supplies to the family; make sure that they understand
how to use the supplies…when to use the supplies; make sure that they know how to
put the furnace filter in the right way, for example, things like that; and just kind of
educate them based on those supplies and grounded in those supplies. And we track all the costs
of the specific supplies, because it helps us establish our return on investment when
we do our internal kind of assessment of the program. I’m not going to take too much
time on this slide, because there’s a lot of information here, but I definitely recommend
that you come back and look at this once the whole presentation’s posted. But these are
kind of the four main areas that we break down our evaluation. The first is asthma severity
in the top left kind of quadrant. The top right, we look at the quality of life of the
family, and that’s through self-report of the family and of the parents. Bottom left,
we look at the behavior of the family, so how often they do things like vacuuming and
dusting, and then bottom right, we take a look at the actual home’s health and safety,
along the eight principles of the healthy home. These are all measures that we conduct
both at the beginning, 6 months after the interventions are completed, and then 12 months
after the interventions are completed, as well, to kind of get a story of how our intervention
affected the family and then an aggregate of all of our families. And we also do quite
a bit of internal assessment, just making sure that our program is consistent and that
we’re not all over the map in terms of the quality of service that we’re providing
or the cost of the service that we’re providing. So these are some of the things that we look
at internally how often we’re enrolling families for more than one program within
our organization; how much the cost per intervention is both on average and just in specific cases
and we look at the cost of supplies as part of that; we look at how many families we’re
able to follow up with, how often or how long families are staying within our program, how
long our construction projects take, how many referrals we make, and where we make those
referrals to. So, those are all really important to us to kind of see the health of the program
and make decisions as we move forward. These are some health and quality-of-life outcomes
for 55 clients as part of a study that we recently did with a local university, The
University of Nebraska Medical Center. So, the paper hasn’t been published yet, but
we got these results actually just a week or so before we received the award. So, we’re
really excited to share them. In the middle column, we have the aggregate, preintervention
numbers for each of the things in the left-hand most column. So, for example, these are the
first row. These are the collective symptomatic days for those 55 clients in the 2 weeks before
our intervention even started, so that’s part of the baseline information we collected,
and then 6 months after our intervention, we collected that same information how many
symptomatic days did your child have in the 2 weeks before we had this follow-up. And
so those numbers dropped pretty significantly from 131 to 11. If we you now go down the
row I’m not going to read them all out but you can kind of see those same kind of dramatic
reductions very similar to what Mobile Care saw. Missed school days went down, missed
work days as a result of those missed school days went down, emergency department visits
went down and so did hospitalizations. And as part of intervention partnerships we had
with the managed care organization, we found that the return on investment for our interventions
resulted in a $1.83 for every dollar that we invested, and so we’re trying to really
push that number up as we reduce the cost of our services and also increase the quality.
These are some of the behavioral outcomes that we see. So like I said, we not only try
to and, like, augment good behaviors that also mitigate bad behaviors or negative behaviors
or so. Trying to encourage their families to dust more and vacuum more and change their
furnace filter more often and consistently, and we find that after our brief education,
it just takes a couple minutes to show them, for example, how and when to change the furnace
filter. We see significant increases in all those positive behaviors, and we also see
significant decreases in some negative behaviors. So smoking indoors, using harsh cleaning chemicals,
and using candles and air fresheners–those are all just very simple small changes that
family makes. The smoking indoors one is one that we’re really excited about, because
that’s part of our program–we require that our family stop smoking indoors, and that’s
a really hard habit to break. It’s not that they’re not smoking at all, but even just
going outside can be pretty significant challenge, especially in the winters in Nebraska; it
can get pretty rough, so that’s one that we’re really excited about. And then here
we just have some photos of the kind of work that we do. This is a surround that was replaced;
you can see there’s some pretty significant mold in the corners and on the walls of the
shower, as well as no ventilation in the bathroom. You can’t really see it on the left-side
picture, but there wasn’t a ventilation system in there. On the right side, we not
only installed the vent fan above that light, but we installed a whole new surround and
made sure that leaking that was causing the mold was taken care of, as well as educating
the family on wiping down the surfaces after a shower or bath and making sure that the
vent fan is on during a shower or bath, which as you all probably know can go a long way.
And this is a survey picture of one of our cleanouts that we do; sometimes we will go
into a house where there’s significant work that we can do on the indoor air quality through
a small construction intervention whether that’s cleaning up a branch out or getting
rid of some mold, but our contractors can actually get into the problem areas of the
house safely. So, then we can enlist some volunteers from the community to work with
the family; we bring out a free dumpster, bring in a team of four or five people and
a couple of staff and really work through cleaning out those areas with the family,
and so, not only does that allow our contractors to go in and do the work that they need to
do, that also reduces the clutter in that house allows the air to circulate better and
just improves the indoor air quality, in general. It’s just a list of some of the partnerships
we have and the types of partnerships we have. So, we have a couple of reimbursement models
that we’re currently working with and on. Some of those are direct, and some of those
are partial, but that’s really exciting for us, because that’s a model that is pretty
progressive and hard to accomplish and set up. So, we’ve been really diligent about
respecting and nurturing those relationships. These are either health care providers or
managed care organizations that are seeing the kind of returns that we have seen and
they are interested in investing in the health of our community, because honestly, it reduces
the load on their system. We also have this Nebraska Asthma Coalition, which is just a
partnership of a lot of stakeholders in Omaha and in Nebraska, frankly, in terms of asthma
or just respiratory or air quality, in general. So, getting a lot of the people in the room
that care the most and then making sure that we can triage or work with them when it’s
relevant. We’ve got some corporate sponsors. One of those is Aware; that’s an indoor
air quality monitor company. They are trying to make those residential and commercial indoor
air quality monitors a thing. So, we wanted to kind of show how they work in our family’s
homes. We have some government partnerships, so the city of Omaha is a big one, and we
do a lot of healthy home construction with them as part of their lead remediation program.
We work pretty closely with Children’s Hospital of Missouri, and we do a lot of mentorship
with them. They train us, we train them; we provide equipment for them, and they trade
equipment back to us. It’s really great back and forth that we have with them, and
then just more health care providers just simple referrals, and then finally that University
that I have mentioned earlier, we really work a lot on the research and internal evaluation
of our program with the students and physicians there that do research on their day-to-day
anyway. And these are kind of our next steps, so this is where we see ourselves going and
where we want to go, so we would very much like to duplicate our model in other places.
We think that the house is kind of the linchpin of health for kids, because kids spend so
much time in their homes. We want to continue to expand this reimbursement model that we’ve
been working on. We see it in a lot of other places, and we want to kind of demonstrate
that there is a return so consistently that it’s almost irresponsible for health care
providers and managed care organizations to not invest in the model. We need to get a
lot more efficient in terms of sharing our claims data and making sure that’s done
securely and in a way that respects the privacy of our clients. We wanted to scale up our
individual services, so moving from 50 homes to 75 or 100 or 200 homes just in terms of
our own program, and then we’ve really have been working on this community-wide automated
referral system, so the idea being that a family might not know what services are out
there, but they know what they need. So, in putting that into an automated form online,
it then sends itself to different organizations and makes sure that they can get service from
programs that they might not know are out there. So, those are some of our priorities
over the next couple of years, and that’s actually my whole presentation. Looking forward
to you guys for questions. Yeah, feel free to reach out to me directly, as well you want
to talk more, and thanks again to the EPA for having this whole presentation. It’s
very exciting to us as an organization. Tracey Mitchell: Great. Thank you so much,
Ian. Project AIR what a great example of tailored environmental inventions and then impressive
evaluation and ROI data as well. Okay, so our last presenter from the Rhode Island Department
of Health is Ashley Fogarty. Ashley has a Master’s degree in Public Health from the
University of Connecticut. She’s been working at the Rhode Island Department of Health Asthma
Control Program for about 3 years. She coordinates services. You’re going to hear more about
partnerships from her program, and she’s involved in various evaluation activities,
as well. So welcome, Ashley. Ashley Fogarty: Thank you, Tracey. Hi, everyone.
As Tracey mentioned, my name is Ashley Fogarty, and I will be presenting on behalf of the
Rhode Island Department of Health Asthma Control Program. So this slide shows data among children
of Rhode Island, as well as health inequities that currently exists in our state. So it
provides a breakdown of asthma-related emergency department visit rates and hospitalizations
per 1,000 children under 18 years of age, and it shows that Black and Hispanic children
have disproportionately higher rates of ED visits and hospitalizations as compared to
white children. Also, our program is focused on the high-poverty urban cities in Rhode
Island, commonly referred to as the core cities, which includes Providence, Pawtucket, Central
Falls, and Woonsocket. Among the four core cities, the rate of asthma emergency department
visits is almost three times as high as the rest of the state. In later slides, I will
be able to provide maps of the state, which shows a visual of the core cities as compared
to the rest of the state in terms of the burden of asthma. So just to continue here with more
asthma data and the health inequities for children living in Rhode Island, as mentioned
in the previous slide, the burden of asthma falls disproportionately on the urban low-income
cities in the state and also falls disproportionately on Black and Hispanic children: children living
in low-income households and children living in low income urban neighborhoods. So, our
program primarily focuses on children with asthma on Medicaid as over 70 percent of pediatric
asthma ED visits in Rhode island are children on Medicaid. These maps show children with
asthma claims living below poverty, as well as children with asthma claims on Medicaid.
The map on the right shows children on Medicaid with an asthma claim, and the map on the left
is a little bit older, but it shows children living below poverty with an asthma claim.
Despite these maps being from different time periods, both maps show a similar trend in
the high-burden areas of asthma or what we commonly call them: the asthma hotspots. You
can see similar trends with the high-burden areas. On the map on the right, the highest
quintiles of asthma are the bright red and same with the dark brown color on the map
on the left. These maps show asthma emergency department visits among children on Medicaid,
and the map on the right highlights the core city areas by census tract. And so this zoomed-in
map also shows the major highways that cut through the asthma hotspots, as air pollution
from motor vehicle traffic is a major environmental trigger of asthma and something that we’re
really interested in. And again, you can see the core cities here that are highlighted,
so Central Falls, Pawtucket, Woonsocket, and Providence. So, just some more maps. These
describe the asthma, poverty and housing in our state. They’re a little bit older. However,
I thought that they were important to include, as they are density maps showing children
2 to 17 years of age who have an asthma claim living below poverty. So that is on the left-side
map. And then children living in low- and moderate-income affordable housing on the
right side. So, the housing density map is especially interesting as many of the state’s
public housing units are located in the areas that are more dense with asthma claims, especially
in the core cities like I had mentioned. And if you focus in on the map on the right for
the city of Pawtucket, the dark red mark on the lower side actually fits directly above
the Pawtucket Housing Authority–which is interesting and part of the reason why we
currently do a lot of work with public housing facilities in the core cities. So, before
getting into details about our specific asthma interventions, I thought that it would be
a good idea to give a brief background about the Rhode Island Asthma Control Program. We’re
housed in the Division of Community Health Inequity, and we focus on the Rhode Island
Department of Health’s three leading priority areas, including socioeconomic and environmental
determinants of health, eliminating health disparities and promoting health equity, and
to ensure access to health–quality health services. The Rhode Island Asthma Control
Program serves children 0 to 17 living in high-poverty urban areas of the state, as
I had mentioned before. We are well known for long-term partnerships across different
sectors, including research, hospitals, public health, housing, environmental, and social
justice organizations. So the Rhode Island Asthma Control Program is made up of home-based
school and clinical asthma interventions. Our two home-based interventions are the home
asthma response program, which is the home-visiting program and I will be discussing that in later
slides, and Breathe Easy at Home Program, which involves the use of code enforcement
inspections if providers feel as though a child’s asthma is being exacerbated by the
conditions of the rental property in which they are living. For the school-based services,
we have Project CASE, which is known as Controlling Asthma in Schools Effectively. This program
encompasses Hasbro Children’s Hospital’s Draw A Breath asthma workshops, school training
for staff, as well as monitoring indoor air quality in schools and promoting the use of
asthma action plans and improving care coordination between providers, schools and families. Okay,
so Rhode Island’s Home Asthma Response Program: This program is an evidence-based intervention
designed to reduce preventable asthma ED visits and hospitalizations among high-risk pediatric
asthma patients. HARP uses certified asthma educators and community health workers to
conduct up to three intensives in-home sessions that assess asthma knowledge, provide asthma
self-management education, deliver environmental supplies, and improve the quality and experience
of care. The Rhode Island Asthma Control Program currently partners with Hasbro Children’s
Hospital in St. Joseph’s Health Center to provide home visits. HARP eligibility is based
on the child’s age, city of residence, the level of asthma control and their use of the
health care system. So this slide shows the HARP screening tool for eligibility into the
program. If you look at the diagram, children with two or more asthma-related emergency
department visits or one inpatient asthma hospitalization, or if they have poorly controlled
asthma, meaning that they experience asthma symptoms on a daily basis, are generally referred
to participate in the full HARP package. So full HARP means that they would be getting
up to three intensive in-home session with the certified asthma educator and the community
health worker. With the full HARP package, participants also receive environmental supplies
as needed, such as HEPA vacuums, cleaning supplies, mattress covers, food storage, containers,
et cetera, in addition to instruction for remediation of environmental triggers. Other
children with–if they have either less emergency department visits or their asthma is not well
controlled, they might receive the one in-home visit or be referred to participate in Hasbro’s
Draw A Breath workshop, which takes place either at the hospital or sometimes in schools.
Rhode Island was selected to be part of CDC’s 6|18 Initiatives in 2016, which targets six
common and costly health conditions with 18 proven interventions. The purpose of the 6|18
Initiative is to promote the adoption of evidence-based interventions in collaboration with health
care purchasers, payers, and providers. So through our participation with 6|18, we participated
in the first cohort, and we had discussions on the reimbursement of the cost of asthma
home-visiting services. The Rhode Island Asthma Control Program submitted a HARP budget initiative
as part of its 6|18 work, which is one of many program efforts to get statewide Medicaid
coverage of HARP for pediatric asthma patients with poorly controlled asthma. The Rhode Island
6|18 Asthma Control Team convened state government officials, providers, and insurers together
to propose a business case for making HARP a Medicaid-reimbursable service. We also worked
with primary care providers participating in Rhode Island’s patient-centered medical
home project, which now has 73 practice sites serving more than 320,000 Rhode Island residents
to implement asthma guidelines-based care. As shown in previous slides through our participation
with 6|18, we are able to use claims data to map HARP-eligible Medicaid members, showing
a disproportionate cost burden for a small population of high-asthma utilizers. We developed
the HARP infographic as shown in previous slides showing a positive return on investment,
presented data to Medicaid and managed care organizations, as well as initiated an MCO
pilot program. And lastly, we were able to map Medicaid asthma data with environmental
determinants and leverage funds from the Volkswagen Clean Air Act Settlement to secure funds for
HARP coverage for Medicaid-eligible children with asthma. We have continued to ensure that
this parallel offer is aligned with the activities within the 6|18 Initiative to create a synergistic
approach to promoting community health workers and team-based care to successes and demonstrated
a cost savings from the asthma home-visiting models. So as I just mentioned about our HARP
infographic this is a piece of the infographic and if anyone is interested, I’d be happy
to share. This infographic shows that we had developed a business case on HARP to show
the cost savings and return on investment of the program. HARP has a positive return
on investment, which means that for every dollar invested, we get returned with additional
savings earned. HARP participants had a 33 percent return on investment on emergency
department and hospital costs, so every one dollar invested returned with an extra 30
cents saved. There have been several demonstrated outcomes for HARP, including quality improvement,
improved asthma control, quality of life, reduction of environmental triggers, and reduction
of missed work in school days, and an increased use of asthma action plans for participants.
This slide provides a breakdown of the median and average cost of care for children with
asthma who are enrolled in Medicaid. As you can see, in 2016, children with asthma who
are on Medicaid costs an average of $9,489 compared to children with asthma who are not
eligible for HARP, who cost an average of $2,652. This breakdown of cost by HARP-eligible
populations compared to those who are not eligible for HARP shows the importance of
investing in this program. Basically, the HARP-eligible group has smaller numbers and
has a much higher cost for asthma care. On top of the uses of Medicaid asthma claims
data described, including the mapping, evaluation, and an economic analysis of asthma from managed
care organizations, we also have used claims data for environmental policy, such as sharing
maps of asthma hotspots overlaid with public transit bus route to help our sister agencies
prioritize asthma hotspots for a Zero Emission Bus Electrification Project. In the future,
we will also be looking at housing instability and displacement within the Medicaid population.
So that is the end of my presentation, and I’ve provided my contact information here
if anyone’s interested in learning more about our programs or receiving any of our
materials mentioned during the presentation. I would also like to acknowledge my colleagues
here at the Rhode Island Department of Health Asthma Control Program, including Nancy Sutton,
who’s the PI of our CDC grant; Julian Drix, the Program Manager; and Deborah Pearlman,
our program consultant lead epidemiologist from Brown University. Thank you so much to
the EPA and Tracey for giving us the opportunity to discuss our program, and I would be happy
to answer any questions. Thank you. Tracey Mitchell: Excellent, thank you, Ashley.
Again, Rhode Island is a great example of integrated health care services within an
impressive ROI, and your important work with Medicaid is really outstanding and we could
learn so much more from you. I’d just like to end by thanking all of our speakers and
congratulating our winners again. My thanks to them for taking the time to share their
best practices and their experiences. As you can see, we could have spent probably another
hour learning from them, but the learning continues. Hopefully, you will be able to
join us immediately following this presentation on to be able to
interact directly with our speakers and ask your questions at that time. They’re going
to be with us till about 3:30, but this presentation, as well as the question and answers, will
be archived on So you’ll have the opportunity to go back
and review and be able to ask questions in the future. At this point, I would like to
again congratulate and thank our winners and invite you to join us on
This concludes today’s webinar. Thank you, all.

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