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Local Resources PanelRachael Greenberg, M.P.H.
Public Health Project Manager
Shawana MitchellHealthy Homes Specialist
National Nursing Centers Consortium
2
National Nursing
Centers Consortium’s
Southeastern PA Lead and
Healthy Homes Program
Rachael Greenberg, MPH
Shawana Mitchell, HHS
Disclosure: Neither I have, my spouse/partner, and/nor family member had any actual or potential
conflict of interest in relation to this CME activity. I agree to disclose to the audience any unlabeled or
investigational use of a commercial product.
3
National Nursing
Centers Consortium
Mission:To advance nurse-led health care through policy,
consultation, programs, and applied research to reduce
health disparities and meet people’s primary care and
wellness needs.
SEPA Lead and Healthy Homes
Program
Our program focuses on improving environmental health in
households with expecting mothers and/or a child under seven
when there is:
– a risk for lead poisoning
– the mother or child is suffering from asthma
– or there are other home health hazards to be addressed.
We can provide a free home visit, including comprehensive
participant education on how to improve the health of the home
and free healthy homes supplies (such as mattress covers and
cleaning supplies).
4
SEPA Lead and Healthy Homes
Program
Where?
– Berks
– Bucks
– Chester
– Delaware
– Lancaster
– Montgomery
– Philadelphia
– Schuylkill
5
NNCC and its partners have served
approximately 850 families since
July 1, 2013.
The Lead and Healthy Homes Program also operates
throughout the entire state of PA, via several other grantees.
Partners
• Abbottsford-Falls Health Center
• Chester County Health Department
• City of Chester Bureau of Health
• Montgomery County Health Department
• Philadelphia Department of Public Health
• PinnacleHealth System
• Temple Health Connection
Funded by the Pennsylvania Department of Health
6
Asthma-Related Medical Visits
Change in rate of asthma-related medical visits over any 3-month
period before and after program participation.
Type of Visit Statistic P-value
Doctor S= -309 .0005*
Emergency Room S= -162 .0752
Hospital S= -173 .009*
There were reductions in the median rate across all types of
medical visits and it was statistically significantly for doctor
visits and hospital admissions.
7
Opportunities
What makes NNCC’s program successful?• Holistic
• Large number of families served
• Collaboration
• Community Health Workers
What can we do to support this in the future?• More collaboration
• Increased, sustainable funding• For Community Health Workers
• For remediation efforts
8
Role in the Community
9
Thank you!
Contact Information
10
Shawana MitchellE: [email protected]
P: (267)-765-2320
Rachael GreenbergE: [email protected]
P: (215) 731-2474
Local Resources Panel
Palak Raval-Nelson, Ph.D., M.P.H.Director, Environmental Health Services
Philadelphia Department of Public Health
To maintain environments, prevent disease, and
promote public health through education and
regulation. EHS monitors, assesses, inspects, and
educates the public about vectors, food safety, lead &
healthy homes, and environmental engineering.
Environmental Health Services
Vector Control
Food Protection
Environmental Engineering
Lead & Healthy Homes
Program
Pb
Child Asthma Hospitalization Philadelphia (2000-2012)
Asthma Related ER Visits Children < 18 yrs. Philadelphia, P A
2009 10,5550
2010 9,958PDPH Syndromic Surveillance System
PA Health Care Cost Containment Council 2010
•Americans spend up to 90% of their time indoors•Indoor concentrations of most pollutants are higher than outdoor
Indoor Environment and Asthma
The Healthy Homes Healthy Kids
Program City of Philadelphia Department of Public Health
• Collaboration with St. Christopher’s Hospital forchildren with severe asthma
• Integrates clinical, environmental and educational strategies to successfully mitigate and manage a child’s asthma, prevent lead poisoning and address other health and safety hazards
• Close collaboration family, medical team and HHHK team to address housing conditions and behavior.
• Services are provided in English and Spanish in anappropriate cultural framework.
1. Reduce Environmental Health and Safety Hazards• Repair Leaks
• Remove mold and repair water damage
• Rip up old carpeting and refinish floors
• Replace leaded windows where children can reach
• Vector Control Unit services (Integrated Pest Management)
• Energy Audit and Weatherization
2. Help Families Engage in Healthier Behavior• Personalized Environmental Action Plan & Motivational Interviews
• Issues include: clutter, tobacco smoke, stop use of perfumes, candles,
noxious cleaning and pest control supplies
3. Partner with Clinical Team• Biweekly calls for information sharing
• Ensure child and caregiver understand and use medication as prescribed
(January 2013 – December 2014) N=160
Activity/Personnel Cost
Remediation $ 3000
Integrated Pest Management $ 150
Staffing $ 110
Client supplies $ 200
Total Cost For HHHK Services per
unit
$3500
Weatherization (selected homes
only)
$1200
Outcome Pre 6-9 months post
Difference % improvement
Hospital visits in last 6 months
1.8 0.6 1.2(p<0.0001)
67%
ER visits in last 6 months
3.7 1.6 2.1*(p<0.0001)
57%
Doctor visits in last 6 months
3.8 2.2 1.6(p=0.002)
42%
Missed school days in last 1 month
3.3 3.6 -0.3(p=0.69)
--
Albuterol use in last 2 weeks
9.3 6.7 2.7(p=0.09)
--
Revised 6.2.15
93 families surveyed based on per and post test questionnaires
It works! It is a cost effective intervention.
Must address both housing condition and residents’ behavior.
Important to involve child’s medical providers.
Important to allow residents to determine their Healthy
Homes priorities.
Must be culturally appropriate and language accessible.
More evidence-based research needed on reducing second
hand smoke in private homes of low income residents.
Funding is needed to support program expansion.
Homeowners need resources to improve housing.
Landlords should be required to adhere to their legal
responsibilities under the Philadelphia law.
Retaliatory evictions are illegal and tenants need adequate
representation.
Next Steps-Goals to Help Philadelphia’s Children
Partnerships
with community organizations, health care
providers, government agencies, health insurers,
housing organizations, landlord associations and
legal services.
Sustainable Funding
for services and home repairs to reduce the
health and safety hazards in homes and support
families’ healthy behavioral changes.
Next Steps-Goals to Help Philadelphia’s Children
Data & Information to develop a robust understanding of housing quality in
Philadelphia, to understand the prevalence of health and
safety housing issues and the impact on children’s health and
to evaluate the effectiveness of interventions.
Legal Services and Other Support to ensure families have the legal services along with have the
information, resources, support, access to health care they
need to reduce the health and safety hazards in their homes.
Enhanced Enforcement of the Health Code, Property Maintenance Code, Lead
Disclosure and Notification Law and other laws as needed to
help improve the housing conditions of children.
Local Resources Panel
Stefanie SeldinExecutive Director
Rebuilding Together Philadelphia
Rebuilding Together Philadelphia
REBUILDING TOGETHER PHILADELPHIA
Mission: RT Philadelphia brings
volunteers and communities together
to improve the homes and lives
of low-income homeowners.
REBUILDING TOGETHER PHILADELPHIA
Volunteers and homeowners
work side by side.
Block Builds:
Partner w/community agency
10 to 25 clustered homes
100 to 300 volunteers/day
1 to 4 days
REBUILDING TOGETHER PHILADELPHIA
RTP is one of 166 affiliates nationwide
PRIORITIES:
Veterans
Disabled
Elderly
Families with children
GOALS:
Healthy
Energy-Efficient
Safe
7 Healthy Housing Principles
Partnership with NCHH to Keep Homes:
Dry
Clean
Pest-Free
Safe
Contaminate-free
Well ventilated
Maintained
Moisture & Infestation Prevention
• Close access points for pests
• Roach & mice droppings
contribute to asthma
• Less pesticides
• Reduce moisture
• Moisture causes mold
• Mold triggers respiratory
issues
Remove Asthma Triggers
Basement clean outs eliminate pest harborage, reduce asthma triggers
Carpet removal reduces dust and tripping hazards
Medically Fragile Children’s Project
St Christopher’s
Center for the Urban Child
affiliated with St. Christopher’s
Hospital for Children
Collaboration to create healthier
and safer home environments
for medically fragile children
Mercy Vocational High School
St Christopher’s
Center for the Urban Child
affiliated with St. Christopher’s
Hospital for Children
Impact Data & Need
40 question survey – pre- and post-build
Avg cost of one home: $6,000
Recent Block Build Market Value
Funding: Corporate, Foundation,
Individuals, In-kind
4,000 on Basic System Repair Waitlist
Age of homes, home insecurity
Rebuilding Together Philadelphia: Partners
Volunteers
Corporate groups (i.e., IBX,
Toll Bros)
Students (Temple School of
Pharmacy, Wharton School
at Penn, Drexel)
Religious groups (churches)
Referrals
National Nursing Centers
Consortium
CDCs
St. Christopher’s Center for
the Urban Child
Resource guide
REBUILDING TOGETHER PHILADELPHIA
27 years of improving lives and revitalizing communities
31,000+ volunteers
450,000+ volunteer hours
$28 million worth of repairs
1,363 homeowners and 60 community agencies.
Local Resources Panel
Richard GibbonsDirector, Bureau of Emergency Medical Services
Pennsylvania Department of Health
Pennsylvania Department of Health
• Bureau of Emergency Medical Services (BEMS)
Oversight / regulation of the EMS system
Community Paramedicine
Community Paramedicine – Value Added
• EMS agencies uniquely positioned in our communities
• EMS are one of the few health care providers with direct access to patients’ homes
• Outreach to the underserved and super-utilizers of the emergency health care system
Is it Working?
Participating in CP
• Estimated savings per patient = $1,200
• Improved quality of life = PRICELESS
Did not participate
• 66% re-admit within 30 days
Funding / Sustainability
• Mostly “start-up” and grant funded to-date
• Hospital or third-party payer supported in some instances
• CONNECT program in Pittsburgh area
What is needed?
• Reach out to your local EMS agencies
• Create sustainable funding --- the cost savings and data support it!
• We are here to fill gaps and expand access to health care.
Richard L. Gibbons, Director
Bureau of EMS
717.787.8740
Local Resources Panel
Tyra Bryant-Stephens, M.D.Medical Director
Community Asthma Prevention ProgramChildren’s Hospital of Philadelphia
Community Asthma Prevention Program
Proving the Case for Community Health Workers
Tyra Bryant-Stephens MD
The Children’s Hospital of Philadelphia
Caroline West, MPAff
Gary Klein, PhD
Before After
Community Asthma Prevention Program
Interventions
Community Classes for Parents School Classes for Students
Home Environmental Asthma Trigger Reduction and Education for families
Home Visits Classes Parent Educators (P) PCPs (S) Schools
“We do not panic! We
have learned to act quickly
& calmly before attacks
occur.”
“ about CAPP. YOU ARE THE BEST kept
secret in
Philadelphia.” I’m telling parents
“…since my home visitor has
been coming weekly…my
children haven’t been to E.R.
in past year.”
“Since taking CAPP asthma
classes, I have learned so
much, but the most important thing is that
asthma can be controlled.”
S
3000 Home Visits
2300 Class Participants
76 Parent Educators Trained
200 PCP’s trained
60 Participating Schools
443 School Personnel Trained
741 Students Educated
CAPP’s Impact in Philadelphia
P S
S
S
S S
S
S
SP
P P
PP
P
BACKGROUND
• African American children are more likely to have emergency room visits and hospitalizations yet less likely to visit their pcp for sick visits.
• Only 50% of the children managed by CHOP inner-city practices returned to the pcp after an emergency room visit.
• High utilization is partially explained by poor asthma control impacted by:– poor adherence, cultural beliefs, psychological stressors, poor clinician-patient
collaboration and long intervals between visits.
• AND Lack of adherence to medication :– suboptimal pcp prescription habits and caregiver concerns about controller
medication side effects.
Background• Tailored asthma interventions that consider the families’ psychosocial needs
and health beliefs are more likely to reduce utilization than health insurance and access .
• Previous studies find that community health workers (CHW) are effective in delivering tailored interventions and coordinating resources in the home and community in a culturally appropriate manner.
• Recent studies have proven that community health workers integration into the patient-centered medical home is feasible and successful.
• We sought to reduce utilization by expanding the role of the CHW in the medical home while maintaining their visibility and interaction with caregivers in the home and community.
1.Bryant-Stephens AJPH 2009 , 2. Crocker, Am J Prev Med 2011, 3. Nurmagabetov, Am J Prev Med 2011, 4. Findley, J Ambul Care Manage 2014, 5. Wennerstrom, Health Promot
Practice 2015
Hypothesis
• Asthma Navigators’ interaction with caregivers of children with asthma will lead to increased follow-up pcp visits resulting in improved asthma outcomes
– Primary Outcome- increased follow-up asthma visits to the primary care provider before readmission and reduced asthma symptoms
– Secondary Outcomes- reduced hospital and emergency room admissions, caregiver satisfaction with asthma navigator, caregiver satisfaction with health care team, improved pulmonary function
Developing the Asthma Navigator Model
Patient Navigation
Yes We CanAsthma
Care Navigator
• Patient Navigator model was first implemented by Dr. Harold Freeman in order to help women with breast cancer navigate the medical system. • Adaptation of Model to asthma in children
• Yes We Can model integrates the CHW within the practice.
• Combining the Patient Navigator and the YWC model allows us to complete the circle of care
Objectives• Identify high risk children with asthma
and enroll in Asthma Navigator care coordination program
• Implement Asthma Navigator model in four (now three) practices– Integrate AN within the clinical team
and office care– Improve
• communication between caregivers and clinical team
• caregiver and patient’s self-management skills
• asthma control
– Connect caregivers with resources– Reduce asthma utilization
61
Asthma Navigator Study Design
• Prospective Case Matched control study
• Enroll 240 high risk asthmatics from three inner-city practices
• Assign to Asthma Care Navigator who is embedded in each practice
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Advances in asthma medications.!Identifying and treating preschoolers with asthma. !Develop protocol for making daycares and schools environmentally healthy. !
Explore ideas of healthy homes. !
Asthma Navigator Program
CHOP Asthma Care Committee
CHOP Asthma Champion Committee
CHOP Asthma Clinical Science
Workgroup
CARE Network
Primary Care Practice Staff
Key Implementation Partners
63
Eligibility Criteria
• 0-17 years old
• 1 inpatient or 2 ED visits in past year
• On at least two controller medications
• PCP in one of 3 CHOP primary care practices
• Medicaid or CHIP insured
Case matched
Control
• Birth year
• Gender
• Ethnicity
• Number of ED or IP visits year prior to identification
Asthma Navigators
• Community Health Workers with a combined total of 23 years experience with asthma
• Assigned to three CHOP CARE Network inner- city offices and integrated into clinical health team
• Residents in inner-city Philadelphia
• Charmane Braxton and Carmen Perez
Asthma Education
• ACN provides one-to-one education for caregivers in the home
• ACN teaches Asthma Care Plan, Controller Medicine, Asthma as a chronic disease, provider communication skills
Home Visits
• ACN makes 3 home visits- assessment, intervention, observation
• ACN identifies common indoor triggers
• ACN assists in removing triggers and distributes supplies
Follow-UpAppointments
• ACN facilitates scheduling appointments, sets up reminders
• Caregivers expected to return every 3 months after initial visit
• Each visit includes: asthma control tool, review of goals, asthma care plan
SchoolLinkages
• ACN contacts school nurse of patient and shares asthma care plan
• ACN empowers caregivers to communicate with school nurse
• After first year, school nurses can refer patients who are patients at CHOP Care Network
Communityresources/Soci
al services
• ACN works with social worker to identify resources for families and to link them with needed services
• ACN meets regularly with social worker to review difficult cases
Core Care Coordination Services
Care Coordination Goal
Set goal N
Met GoalN
Met Goal%
Interventions Barriers
Make and keep follow- up appts
203 148 73 Phone callsAN facilitate schedulingTransportation tokensInsurance co transportation
No ShowsNumber changedNo insuranceParent forgot
Learn how to properly use meds
122 122 100 One-on-one education in office and reinforced in the home
Patient flow
Reduce asthma triggers 203 203 100 Home visits identifiedcommon triggers and taught avoidance techniques
Scheduling No showsRenters
Stop smoking in the house and car
53 29 58 Home visitsNo smoking zoneNo smoke pledgereferrals
Smoker not ready, stress, can’t make family members
Help with transportation to the provider
50 38 76 Referrals to health care insurers’ transportation resources; tokens
Transportation for entire family, not just the patient being seen that day
Baseline Demographics
68
Control n=254 Study n=254
Age 4.96 years (±3.6) 4.97 years (±3.5)
African-American (race) 94.5% 93.4%
Male (sex) 61.3% 64.8%
Well Controlled 28.9% 16.0%
Uncontrolled 9.5% 19.9%
Poorly Controlled 20.9% 30.9%
Missing Data 40.7% 33.2%
SURVEY DATA OF STUDY GROUP
Within group results…
Methodology
• MCAN caregiver Survey completed at baseline and repeated at 12 months used by four sites.
• The survey instruments included questions addressing the following domains:– patient demographics
– health care utilization
– asthma control
– asthma medications
– asthma symptoms
Home Assessments
• Asthma Triggers present at baseline and 12 months
• Home condition
• Remediation actions taken within the home at 12 months
Row House 85.1%Apartment 13.3%Rent home 78.5%Forced air heat 68.1%Use a space heater to heat home 13.4%
Family owns a vacuum cleaner 49.2%
Living RoomUpholstered furniture 85.9%Wall-to-wall carpet 41.3%Air conditioner 55.4%
Child’s BedroomCarpet 49.2%Blinds, curtains or drapes on windows 97.0%
Stuffed animals 64.6%Vaporizer 12.9%Open shelves 20.6%Ceiling or window fan 42.7%Air conditioner in window 50.0%Closet with door/cover 87.5%
Number of people who regularly sleep in child’s bedroom 1.69 people(±0.70)
Baseline Home Characteristics
Survey Symptom Data Meandays
Baselinen=254MeanDays12monthsn=254
p-value
Misseddailymedicine(inpast2
weeks)
1.48(±3.3) 1.20(±2.6) Notsignificant
Tookrescuemeds(inpast2weeks)
5.87(±5.8) 2.74(±3.5) .000
SymptomDays(inpast4weeks)
6.78(±7.9) 3.00(±5.2) .000
SymptomNights(in
past4weeks)
7.00(±9.3) 2.42(±5.2) .000
SlowedActivity 5.50(±8.6) 2.51(±5.7) .000
SchoolDaysMissed 9.77(±11.5) 2.82(±3.3) .000
WorkDaysMissed 9.16(±16.7) 1.52(±3.0) .000
Asthma Triggers in Home Environmentn=254
First Home Visit Last Home Visit P-value
Roaches 29.0% 15.1% p<.001
Rodents 72.5% 61.3% p<.001
Smokers 40.2% 38.5% NS
Pets 38.6% 34.8% p<.006
Wall-to-wall carpet 41.3% 38.9% p<.057
Wet basement 13.5% 2.0% p<.001
Upholstered furniture 85.9% 85.7% NS
Stuffed animals 64.6% 33.5% p<.001
Healthcare Utilization-self-reported
MeanvisitsBaselinen=254
Meanvisits12monthsn=254
p-value
Unscheduledvisitsbecauseofasthma(in
past4months)
1.91(±6.4) 0.84(±1.1) .012
TreatedinER(inpast12months)
3.83(±3.7)
1.41(±1.6)
.000
Timesadmittedtohospital(inpast12
months)
1.90(±1.7)
0.57(±0.9)
.000
Cost Analysis for Survey Results
Data: Survey Records
• Data collected:
– Child’s medications (survey only)
– During the past twelve (12) months:
• Unscheduled visits to doctor’s office
• ED visits for asthma
• Hospitalizations for asthma
MedicationsMedications Baseline Follow-up Change
At least 1 medication 253 253 0
2 medications 253 253 0
3 medications 141 167 26
4 medications 65 68 3
5 medications 16 9 -7
6 medications 2 3 1
Total Medications 730 753 23
Number (mean) 2.89 2.98 0.09
Days medications skipped
(mean) 1.49 1.20 -0.29
Medications
Medications Baseline Follow-up Change
ALBUTEROL 236 242 6
FLOVENT 221 222 1
SINGULAIR 109 137 28
ADVAIR 78 94 16
ZYRTEC 25 31 6
ALL OTHER 61 27 -34
Medication Costs
Baseline Follow-up Change
Total Costs $43,800 $45,180 $1,380
Cost per Patient $173 $179 $5.46
Physician Visits
Baseline Follow-up Change
Survey: Unscheduled visits to
doctor
1.55 0.85 -0.70
45%
Cost of unscheduled visits, per
patient
$163 $90 -$73
Emergency Department Visits
Baseline Follow-up Change
Survey: Any ED visit for asthma
symptoms
3.83 1.41 -2.43
69%
Cost of ED visits, per patient $1,604 $589 -$1,015
Hospitalizations
Baseline Follow-up Change
Survey: Any hospitalization
visit for asthma symptoms
1.89 0.57 -1.32
70%
Cost of hospitalizations, per
patient
$13,728 $4,116 -$9,612
Total Costs per Patient
Baseline Follow-up Change
Medications $173 $179 $5.46
Physician Visits $163 $90 -$73
Emergency Visits $1,604 $589 -$1,015
Hospitalizations $13,728 $4,116 -$9,612
Total $15,668 $4,974 -10,694
Summary
• Interaction with Asthma Navigators led to increased number
of follow up visits to the pcp
• Asthma Navigators (CHWs) were effective in reducing
health care utilization resulting in reduce costs for high risk
children diagnosed with asthma
• Asthma Navigators promoted national asthma guideline
care in primary care practices
Conclusions
• The Asthma Navigator program successfully integrated CHWs into the clinical setting while providing much-needed support to the caregivers of high risk children with asthma.
• The asthma navigators promoted national asthma-guideline based care in the home and in the office which resulted in increased primary care office acute visits, reduced asthma symptoms and reduced healthcare utilization.
• The value added by this program has been acknowledged by the practices and the insurers evidenced by their willingness to support and sustain these asthma navigators.
Implications
• Medical homes that incorporate CHW as asthma navigators into their health care team may promote parent/caregiver satisfaction with their health care providers.
• Integration of the CHW into the health care team may be helpful for other chronic diseases
• Pediatricians should consider advocating for reimbursement of care coordination services by nontraditional health workers for all high risk asthmatic children.
Acknowledgements Caregivers and children of the CARE network practices Asthma Navigators- Charmane Braxton, Carmen Perez Svetlana Ostapenko and Marianne Chiutti Bob Grundmeir MD Karabots Care Network- providers and staff Cobbs Creek Care Network- providers and staff South Philadelphia Care Network- providers and staff Nicole Brown, student intern Asthma Champions
Natalie Minto MD Debbie Voulalas MD Laura Gessman MD Susan Brennan RN Gail Benincasa RN
CHOP Asthma Care Committee Lisa Biggs MD Steve Wilmot
Q&A Discussion
Moderated by:Tyra Bryant-Stephens, M.D.
Medical DirectorCommunity Asthma Prevention Program
Children’s Hospital of Philadelphia
Reference: EPA Asthma Program
