Helping Children Breathe and Thrive in Chicago’s Public Housing Final Report 11/30/13 Sinai Urban Health Institute Sinai Health System California Avenue at 15th Street Chicago, Il 60608 Report prepared by: Helen Margellos-Anast, MPH, Senior Epidemiologist Melissa Gutierrez Kapheim, MS, Epidemiologist II Jessica Ramsay, MPH, Supervisor of Program Initiatives Tala Schwindt, MPH, Epidemiologist I Report submitted to: Department of Housing and Urban Development Office of Healthy Homes and Lead Hazard Control Grant #: ILLHH0223-10 Funding Period: 4/1/2011-8/31/2013 Communication should be directed to: Helen Margellos-Anast Principal Investigator Sinai Urban Health Institute California Avenue at 15th Street, K436 Chicago, IL 60608 773-257-5259 (phone) helen.margellos@sinai.org HUD Final Report Summary Chicago has been documented as one of the hardest hit cities by asthma. The Helping Children Breathe and Thrive (HCBT) program worked with a total of 158 residents (73 Adults, 85 children) living in six Chicago Housing Authority (CHA) buildings: Lawndale Gardens, Horner-Westhaven, West End/Jackson Square, Harrison Courts, Loomis Courts and Park Douglas, all in Westside Chicago communities. CHWs were trained and went into the homes of program participants and their families to conduct comprehensive asthma education, including assistance building a relationship with their primary care provider (PCP). Adults received four home visits over the course of six months, and children received five to six home visits over the course of one year. The primary objectives were to: 1) decrease asthma-related morbidity; and, 2) improve the family’s quality of life. Within Objective 1, there were 3 sub-objectives: a) Decrease frequency of asthma symptoms; b) Decrease urgent health resource utilization; and, c) Decrease activity limited days (days child could not attend school or carry out his/her usual activities; days caregiver missed work). The 3 intermediate objectives were to: 1) decrease the number of asthma triggers that children are exposed to in their homes by improving the home environment and addressing smoking reduction and relocation; 2) improve asthma-related knowledge of the child’s primary caregiver; 3) improve access to medical care and use of an Asthma Action Plan. Results suggest progress was made towards all the mentioned objectives. As one example, the results show dramatic reductions in daytime symptom frequency and urgent health resource utilization. Outcomes reveal statistically and clinically significant improvements in participants’ quality of life. I. Assessment of original work plan Asthma is one condition that disproportionately affects poor and minority children living in inner-city neighborhoods, especially those living in public housing. The project, Helping Children Breathe and Thrive in Chicago’s Public Housing: A Healthy Homes Partnership (HCBT), worked with the Chicago Housing Authority (CHA) to implement an asthma home environmental intervention in six public housing developments. The program utilized the Community Health Worker (CHW) model, employing building residents as CHWs. HCBT used housing as a platform to improve health outcomes, by providing general building education sessions on healthy homes, linking children and adults with asthma to a medical home, and ultimately reducing asthma severity and improving quality of life for those living with asthma in six CHA developments. An in-depth evaluation was conducted, documenting the process of the intervention and the associated outcomes and cost-savings. To build capacity and partnerships, the findings have been shared with community residents, public housing officials, medical providers, and the larger public health community and we continue to disseminate this work to additional audiences when possible. The strategy laid out in the original grant application needed some minor refinements in order to ensure that we would successfully meet the proposed goals of reducing asthma morbidity and improving quality of life among CHA residents with asthma. These changes were made mainly to our recruitment strategy and population enrolled. First, we originally set out to recruit children into the intervention by going door-to-door and screening each child for asthma. We quickly realized that this was not an efficient or effective means of identifying children with asthma and enrolling them into the intervention. After several months of struggling to make this work, we met with our partner, CHA, and came up with a new recruitment plan. This revised plan entailed working closely with CHA case managers who were already interacting with residents. We also added four additional CHA developments, allowing us to work with a total of six CHA developments. We increased our outreach to community organizations and set-up bi-weekly meetings with all persons involved with recruitment, including all our partner organizations, so that we could make sure we were on track to meet our recruitment goal. Because of this delay in recruitment we also had to adjust our grant timeline. We realized that we needed additional time to meet our recruitment goal of enrolling 150 participants. We therefore came up with a revised recruitment plan and requested a no-cost extension from HUD. We were therefore able to recruit for 15 months total, enrolling our final participant in August 2012. We worked closely with our program officer at HUD, Rachel Riley, to come up with a strategy to meet our recruitment goal and maximize our resources. A second substantial change that was made to our grant procedures involved our enrollment population. In the original grant we stated that we would enroll 150 children with asthma into a 12-month intervention. During our initial recruitment phase, the CHWs working on the project encountered a lot of adults with asthma. Since our grant was 1 P a g e originally slated to work exclusively with children, we were unable to enroll these adults into the HCBT program. However, we quickly came to realize the great need of the adults that we were turning away. In most instances, these adults had very severe asthma and very limited information on how to properly manage their asthma. We proposed to HUD the possibility of pilot testing the feasibility and potential effectiveness of a CHW home visit model for adults by enrolling the adults we were encountering into the intervention. In this way we would be able to meet the project’s enrollment numbers while also assisting adults in need. As the evidence regarding the effectiveness of CHW home visit models with adults is limited, proceeding in this manner was a bit of a risk, however it was agreed that the benefits would outweigh any risk. To our delight we were able to enroll enough adults into a 6-month intervention to pilot test the intervention, opening the door for future studies. HCBT has taught us a lot about effectively working with adults in a CHW-led home asthma intervention. We have now been afforded the opportunity, through a new HUD Healthy Homes grant, to further develop and formally test an adult intervention approach with a larger sample size, building upon the lessons learned from HCBT. II. Grant Accomplishments The two primary objectives of the HCBT asthma program were to: 1) decrease asthma-related morbidity; and, 2) to improve the family’s quality of life. Within Objective 1, there were 3 sub-objectives, to: a) decrease the frequency of asthma symptoms; b) decrease urgent health resource utilization; and, c) decrease activity limited days (days child or adult could not carry out his/her usual activities). The 3 intermediate objectives were to: 1) decrease the number of asthma triggers in the home environment; 2) improve asthma-related knowledge; and, 3) improve access to medical care and use of an Asthma Action Plan. The results of each of these objectives are presented below in Section VI. The HCBT intervention was primarily carried out by CHWs, who were hired from two of the CHA developments served by the project, Horner-Westhaven Park (HW) and Lawndale Gardens (LG). Upon being hired, each CHW participated in over 75-hours of rigorous asthma and healthy homes training. Prior to being allowed to teach independently, CHWs underwent a standardized evaluation process conducted by a Certified Asthma Educator (AE-C) and asthma Program Supervisor. The CHW training and evaluation process are described below in further detail on page 3. The recruitment and enrollment process began with a “kick-off event” at HW on July 22, 2011 and at LG on July 30, 2012. All residents were invited, with over 200 people attending the event at HW, and over 100 at LG. Those in attendance were given the opportunity to enroll any child with asthma into the program. Other enrollment activities included door-to-door screening, setting up tables at CHA and other community-related events, and working with community-based organizations and other partner agencies to obtain referrals of adults and children with asthma to the program. In order to improve the process and meet enrollment numbers, HCBT staff began working more closely with our partner, the CHA, as well as the on-site social service agency, Family Works. The addition of four more CHA developments also helped to improve program enrollment. Lastly, instead of only enrolling children as originally planned, the program made the decision (with approval from HUD) to begin enrolling adults. This decision was made to accommodate the large number of adults with asthma that were discovered during recruitment, and who expressed interest in the program. In order to fine tune the referral process via Family Works case managers and other CHA staff at the six developments, bi-weekly phone calls were held for several months early on in the project. Additionally, HCBT staff maintained and shared monthly spreadsheets for each site in order to track the status of referrals, updated information on enrollment, scheduled home visits, and participants who were hard to reach. These activities proved to be very helpful in implementing a successful enrollment process with all project partners. Once enrolled in the program, children with asthma and their families participated in 5-6 home visits over the course of a year, and adults participated in a shortened intervention consisting of 3-4 home visits over the course of six months. CHWs provided comprehensive asthma and healthy homes education to participants, as well as assisted with finding and/or building a relationship with a Primary Care Physician (PCP). In order to ensure the quality of the intervention, a thorough quality assurance process was developed, involving regular shadowing of CHWs and follow-ups with participants by both the project Research Assistant and CHWs. In addition to the home visit based intervention, the program conducted several building education sessions that were open to all residents. Some of the topics covered included healthy homes, integrated pest management, and navigating the healthcare system, among others. Parent group sessions and other community events specifically related 2 P a g e to asthma were also conducted. These activities are discussed in more detail in the next section of this report. Throughout the two year program, HCBT staff also disseminated asthma education to the community by providing asthma basics workshops to several organizations, and participating in health fairs and other community events. III. Tasks and activity assessments a. CHW Training and Evaluation Prior to beginning home visits for the program, Community Health Workers (CHWs) completed a rigorous 76.5 hours of training and evaluation. Components of this training included: asthma basics, healthy homes, program protocol, data collection, and home assessments. Each CHW also completed three levels of mock asthma education sessions, during which they were evaluated for competency using the CHW Asthma Education Evaluation Tool (Appendix A). This tool was created and tested by the program. Both CHWs received a certificate of completion once they met requirements for the training and passed the evaluation. CHWs were accompanied by their supervisor (Intervention Coordinator) for the first 5-6 home visits with program participants in order to ensure the education was being conducted correctly and that data was being collected properly and in an efficient manner. CHWs met with their supervisor after each observed visit in order to discuss what could be improved upon for future visits and what was done well. After these 5-6 observed visits, CHWs were able to conduct visits on their own, but continued to be observed and evaluated at random time points (with the CHW Field Evaluation Tool) every 2-3 months to ensure the quality of the education and data collection continued. This process is discussed further in the “Quality Assurance” section of this report. b. Recruitment and Enrollment As mentioned previously in this report, HCBT staff collaborated with CHA case managers in order to improve the recruitment and enrollment process, after door to door and community event recruitment efforts proved less successful than initially expected. Case managers screened families for asthma whenever they were making home visits and faxed all referrals to the HCBT Research Assistant (RA). The RA then made a phone call to the participant to explain the program and schedule a home visit. Additionally, when residents came into the management offices for assistance with other housing or social service issues, management staff members were able to provide information on the program and fax or call in referrals to HCBT staff. In some cases, HCBT staff or case managers saw residents in the community that they were unable to reach at home and screened them for program eligibility then. This recruitment method was our most successful. In fact, 62% of our overall referrals came from CHA case managers and 70% of those referred in this manner enrolled in the program. The four CHA developments that were added to our original two were: Jackson Square/West-End, Loomis Courts, Harrison Courts and Park Douglas. This strategy along with the enrollment of adults greatly assisted us in meeting our recruitment goal. As also discussed above, the use of bi-weekly spreadsheets to track and communicate between CHA, Family Works and HCBT staff proved effective in keeping all project partners up to date on the program and enrolled participants. After the recruitment and enrollment phase ended, tracking spreadsheets were sent out to CHA and Family Works monthly instead of bi-weekly. We successfully recruited 158 participants into the program. Seventy-three adult participants were enrolled into the six-month intervention and 85 children were enrolled into the 12-month intervention. Figure 1: Recruitment and Enrollment Flow Chart 3 P a g e c. Quality Assurance As mentioned above, the Intervention Coordinator regularly shadowed the CHWs in order to ensure the quality of the education being provided to program participants remained high throughout. Utilizing the CHW Field Evaluation Tool (Appendix B), developed by the Intervention Coordinator, each CHW was scored on a Likert Scale of 1-5, on several different competency areas throughout the home visit (e.g., CHW prepared with all necessary teaching tools, proper teaching of device use, adequate delivery of asthma management information, etc.). Each individual competency score was then totaled and averaged for a final overall score. The CHW must have an average score of 3 or higher to “pass” the evaluation. If this score is achieved, then the CHW is shadowed again in 2-3 months. If this score is not met, the CHW would meet individually with the Intervention Coordinator to discuss areas of improvement and to schedule an additional shadow. Throughout the intervention, each CHW was shadowed a total of 4 times, and the average score on the CHW Field Evaluation Tool was 3.0. Every Friday, CHWs met with their supervisor individually to review paperwork and to discuss the visits that took place over the past week. All paperwork needed to be completely filled out prior to the weekly meeting, including a paragraph (4 sentence minimum) synopsis of each visit. After reviewing the paperwork and discussing any necessary changes with the CHW, the Intervention Coordinator signed off on the paperwork and turned it into the RA so that the data could be entered into the program database. If any discrepancies or questions arose during data entry, the RA discussed them directly with the CHW and/or Intervention Coordinator to ensure the information entered was accurate. Program participants were contacted by the RA for data collection purposes on a monthly basis. Monthly data collection focused on monitoring progress towards improving asthma management (e.g., frequency and severity of symptoms, health resource utilization, etc.) This check-in also allowed an opportunity for the RA to follow up more generally with the participant, concerning their well-being and that of their family. Any important occurrences would be relayed to the CHW as necessary. Based on the data collected by the RA during the monthly phone calls, monthly reports were created which the CHWs and Intervention Coordinator reviewed for important markers of asthma control including the progression of symptoms, quick-relief medication use, ED and urgent care visits, and missed school and work days. If an increase or significant change was noted in these areas for a given participant, the CHW would immediately contact the participant in order to inquire further about the occurrence and to provide support and supplemental education over the phone. In some cases, the CHW would also go to the home to provide additional education in between official intervention home visits. These follow up activities proved to be very helpful in monitoring the quality of the intervention and ensuring that the participants receive the necessary support in real time. The Asthma Q&A Update Sessions for CHWs also served as a method of monitoring and improving the quality of the overall intervention. These sessions were developed by the HCBT Intervention Coordinator along with a Supervisor of another asthma program at the Sinai Urban Health Institute. The purpose of the sessions were to keep CHWs up to date on the latest research and information in the field of asthma, as well as to give the CHWs opportunities to discuss each other’s questions and topics of interest based on experiences in the field. Topics for discussion had to apply to the home visit education process so that each CHW could benefit from the discussion and apply new information and findings to future visits. Q&A Session topics included: Understanding bronchitis; COPD and asthma; Blood pressure and asthma; Use of peak flow meters; Recent topics in asthma related research; Understanding the NHLBI asthma severity chart; Improving patient and educator goal setting; Navigating the health care system; Staff emergency Asthma Action Plan; Allergies and asthma; and Introduction to FeNo Testing in asthma patients. d. Communication with physicians and clinics HCBT staff worked with area health clinics to inform them about the program and to establish methods of working collaboratively to improve the lives of children and adults living in public housing. A letter was sent to each participant’s physician informing the doctor about their participation in the program. This served as an opportunity to inform the physician about the medication the patient was using, triggers in the home, allergy testing and other barriers to proper asthma management. A letter was sent to the physician after the baseline, 6-month and 12-month visit in order to communicate the participant’s progress throughout the intervention, as well as to verify that they had the correct medications in the home. Physicians were asked to review the contents of the letter and correct any discrepancies in the patient’s medication regimen and/or status of up-to-date allergy testing, and to inform HCBT staff of any changes to be made. Asthma Action Plans (AAPs) were also faxed along with each letter and physicians were asked to review, sign and return the AAPs in order to have an official plan in place for the participant. 4 P a g e Another method of communication with physicians and clinics included calling the physician’s office directly regarding a program participant. CHWs and the Intervention Coordinator called to verify a medication for participants, help schedule appointments with physicians, notify the physician of symptom development, and to inquire about the participant’s AAP, allergy testing or other service. Although some physicians were difficult to reach, for those that did respond this was a helpful step in building a relationship between the participant and their physician. e. Asthma Action Plans It was also a goal of the project to create an Asthma Action Plan (AAP) for every participant, and to have the AAP confirmed and signed by the participant’s physician. AAPs were created with the participant at either the first or second home visit, provided the person had prescribed medications. If they did not have medications, the CHW worked with the participant to schedule a visit with the PCP in order to be seen and get updated asthma medication prescriptions before completing an AAP. Once the AAP was completed, the CHW left a copy in the home with the patient and faxed a copy to the participant’s physician along with the physician letter. Physicians were asked to review the AAP, sign, and return it. As with physician letters, participant AAPs were faxed at Baseline, 6-month and 12-month home visits in order to keep it up to date. The Intervention Coordinator and CHWs frequently called physician offices to ensure the AAP was received and to ensure that it was signed and faxed back. However, as is discussed in further detail below and outlined in the flow chart in Appendix C, there were several barriers to getting a signed and returned AAP such as clinic or physician office failure to fax back the AAP, or the patient not having had a recent doctor visit. AAPs were not faxed for those that participated in one-time teaching visits only. Even if a participant’s AAP was not faxed or was not signed by a physician, all 158 program participants were left with an AAP completed by the CHW in the home. Of the 122 total AAPs that were faxed to physicians in an attempt to get their signature, 79 were signed and returned by the physician (65%). The reasons for not receiving a signed AAP are further outlined in the flow chart in Appendix C. f. Uninsured Adult Participants One major challenge encountered during the course of the program was uninsured adult participants. Twenty of the adults (27.4%) enrolled in our program did not have health insurance. Many of our uninsured adult participants had expired asthma medications, no refills, and/or did not have asthma medications at all. In order to address this challenge, HCBT staff provided uninsured participants with a list of clinics that accept uninsured patients on a sliding scale. If the participant was unable to pay for the first visit, we helped them with the payment and accompanied them to the first visit in order to assist with completing necessary paperwork for continued financial assistance. This process was successful in assisting a number of uninsured adult participants to see a doctor and to obtain asthma medications. However, three participants still remained unseen by a doctor due to difficulty with scheduling or not feeling comfortable with neighborhood clinics that offer a sliding scale. In an attempt to make the process easier to follow and to further ensure that participants see a doctor in a timely manner, we worked to establish a more direct arrangement with the Sinai Medical Group (SMG) for uninsured participants in the asthma program to be seen by a SMG primary care physician (PCP). As of early July, 2013, this arrangement is now in place. We believe that this more direct “referral” process will continue to be beneficial in helping uninsured adult participants to see a PCP for asthma management in a more efficient manner. Additionally, patients will have access to other doctors and services within the Sinai Health System as well as access to financial assistance, if they wish to make SMG their medical home. g. Housing/Home Environmental Issues Early on, HCBT project staff and CHA staff collaborated to develop a process for referring housing issues from program participants to building management. If a housing issue, particularly one that is an asthma trigger, was identified and reported to the CHW at a home visit, HCBT staff completed a housing issue referral form and sent it to CHA case managers. The issue was then assessed and sent on to the appropriate management staff member. It is important to note that issues were only referred if the resident asked and gave permission for assistance from the HCBT program in resolving the problem. Participants were always encouraged to go directly to management with housing referrals as well. 5 P a g e Throughout the course of the program, there were a total of 72 individual housing issues referred from 30 different households. Eighty-five percent of these housing issues were from Horner-Westhaven Park residents, with the remaining 15% of the issues being referred from Lawndale Gardens, Jackson Square/West-End, Harrison and Loomis Courts. No issues were referred from Park Douglas, which is a newly constructed development. Table 1 below shows the total number of individual issues reported across all households, as well as the total number of issues resolved and unresolved. Table 2 shows the number of households that reported each issue. Table 1: Total number of issues reported across all households.* Type of Issue Total # Issues # Issues Resolved # Issues Referred Unresolved Carpet 17 10 7 Cracks and Holes 17 17 0 Mold 15 14 1 Pests 4 4 0 Water Damage 6 6 0 Bed Bugs 3 2 1 Other 10 9 1 Totals 72 62 10 *Some households reported more than one of each type of issue. Table 2: Total number of households that had each type of issue addressed and that reported each type of issue.* Type of Issue # Households that had # Households reported issue addressed issue Carpet Removal 10 17 Cracks and Holes 11 11 Mold 9 10 Pests 4 4 Water Damage 4 4 Bed Bugs 1 3 Other 6 7 Total 45 56 *Households may have reported more than one type of issue. The largest numbers of referrals were for carpet removals and cracks and holes. Carpet harbors dust and other allergens that trigger asthma. In three of the homes, there was also mold growth found in the carpet stemming from unresolved leaks. In addition to being the most common referral, carpet removal is also the lengthiest process; paperwork must be completed and submitted to management by the resident and the doctor must also submit paperwork verifying the participant’s asthma diagnosis and/or submitting a letter of support for the carpet removal. Seven of the 17 carpet removals were not yet completed by the end of the program due to the residents still working on completing and submitting the proper paperwork, either on their end or on their physician’s end. Cracks and holes were found in various places in the foundation of the housing units. Cracks and holes are entryways for pests such as roaches, mice and rats, all of which are asthma triggers. One hundred percent of the cracks and holes referred were resolved by management. Mold was also a commonly reported issue, particularly in laundry rooms, kitchens and bathrooms where there is a lot of moisture. All but one of the mold issues reported were resolved and the outstanding issue is in the process of being completed by management. All participants were instructed by their CHW on how to abate small amounts of mold and prevent it from growing by cleaning with vinegar and water, an asthma friendly green cleaning product. In cases where mold was present but able to be abated with the help of the CHW, no referral was made to management. Water damage referrals were mainly due to leaking pipes under the floor boards or in the ceiling and in some cases caused buckling in and cracking of the ceiling and wall. 6 P a g e The four pest infestation referrals were severe cases. In several other cases, management had already been notified and involved. HCBT also recommended the use of boric acid, gel baits and traps to participants. Although they are not directly triggers for asthma, bed bugs can severely impair a family’s quality of life and increase stress levels which can then in turn exacerbate asthma. Several participants and their families reported having dealt with bed bugs, and three were officially referred to management through HCBT. Lastly, the “other” category represented issues such as heaters and air conditioners in need of repairs, visible dust build up in the vents, and handicap accessibility issues. The accessibility issue was not resolved as it was a more complicated issue that was handed over for management to navigate. Overall, 86% of the housing issues referred were resolved. Several participants reported that the resolution of these issues helped to significantly decrease the frequency and severity of their asthma symptoms and increase quality of life. Participants seemed to report the greatest improvement in asthma management from carpet removals. One participant stated “I cannot express how happy I was that one day in July of this year when the contractors arrived at my apartment to pull out the old carpet and tile the entire apartment”. h. Smoking Cessation An on-going challenge faced throughout the HCBT program was the high number of program participants that smoked, and/or lived with a family member who smoked inside the home. We established a partnership with the American Lung Association’s Illinois Tobacco Quitline, a free phone-based smoking cessation counseling service. This has allowed us to refer enrolled HCBT participants and/or their family members to the Quitline to receive the free services, including Nicotine Replacement Therapy (NRT) if needed and desired by the participant. While this seemed like a great opportunity to offer our program participants a service and many expressed an interest in engaging in the Quitline program, few actually followed through with the services. Specifically, a total of 19 HCBT participants and their family members were referred to the Quitline, but only 5 (26%) followed through with the smoking cessation services. This could be due to the regularity with which many participants changed phone numbers, thus making it difficult for Quitline staff to reach them, or it may reflect a lack of true readiness by participants to engage in services. In addition to offering the opportunity to be referred to the Quitline, CHWs provided basic smoking cessation and smoking reduction tips to program participants. For example, those participants that smoked inside were encouraged to attempt smoking outside only, not only to help them cut down on the amount they smoke but for the health of others in the home. CHWs learned these tips from attending Smoking Cessation Trainings, discussed later in the “Outside Trainings and Additional Education” section of this report. IV. Outreach and Education The HCBT team provided education in the communities served by the project via individual home visits as well as via building education sessions and asthma education sessions. Additionally, staff provided asthma 101 workshops for organizations in the community and attended health fairs and other events upon request. Each home visit, over the course of twelve months for children and six months for adults, focused on a different aspect of asthma management. The CHW provided tailored education sessions to each participant and/or their family, centering the education on the family’s learning needs and addressing other issues that may be impacting on the family’s ability to manage their or their child’s asthma. Table 3 below outlines the caregiver learning objectives for each visit in the 12-month intervention for children. The six-month adult intervention has the same focus and objectives for the participant, with the program wrap-up being a part of the six-month rather than the twelve-month visit. Please note that the teachings and objectives for each visit varied from family to family depending on the individual situation. For example, if a participant did not have medications present in the home on the first visit, device use was not covered until the participant was able to get the medication. 7 P a g e Table 3: Focus of home visits for 6-month and 12-month interventions Home Visit Baseline 2-week 3-month 6-month 9-month 12-month Focus -Asthma Basics (e.g. pathophysiology, symptom recognition, purpose of medications and device use) -Home Environmental Assessment/Walk-through -Trigger avoidance strategies -Housing issue referrals as needed -Correct use of AAP -Reinforcement of information from previous visits -General follow-up -Home Environmental Assessment -General follow up -Overall Program wrap-up (for adults) -Reinforcement of all aspects of asthma management -Reinforcement of all teachings, overall program wrap-up (for children) Bi-monthly building education sessions were held at HW and LG throughout the program. All residents of each of the developments were invited to these sessions. To publicize the events, CHWs distributed flyers to individual households, and Family Works and management at each site also assisted in distributing flyers during their home visits and via email. Each session had a different focus. Topics included: • Green Cleaning • Integrated Pest Management • Healthy Cooking • Exercise • Smoking Cessation • Nutrition • Navigating the Health Care System A total of 346 people attended the 7 building education sessions. This exceeded our original attendance goal set at the beginning of the project by 73%. Two events that were of particular interest were the Healthy Cooking Demonstration and the Exercise session. The Healthy Cooking session was held at Leamington Foods in December of 2011. Participants were bused from their respective communities to a local grocery store where they watched a healthy cooking demonstration put on by a Mt. Sinai chef. Each attendee was then given a copy of the recipe that was cooked, in addition to other healthy recipes, along with a stipend to purchase the items on the recipe “grocery list”. Forty-five people attend the event and HCBT staff received a great deal of positive feedback from this event. The exercise sessions were held in February of 2012. A fitness instructor from a nearby Humboldt Park physical activity initiative conducted an hour long Zumba (exercise-dance) class for residents that attended. Both classes were a lot of fun and residents of all ages – children, adults and seniors – attended at both sites. A total of 30 residents attended the sessions. Attendees had a lot of questions for the instructor after the class about continuing to exercise regularly, the benefits of exercise and what types of classes are available in their community. In the original grant proposal, we had planned to conduct bi-monthly parent group sessions for the parents of children enrolled in the program. Two of these sessions were held in the early stages of the program. However, once we began enrolling adults into the program, we felt it was beneficial to open these asthma-specific sessions/events to all participants and residents. A few different types of session were held, but all focused on asthma: Asthma and Exercise (parent group); Asthma and Schools (parent group); Mini Health Fair (partnered with Mobile C.A.R.E. Foundation asthma van); Asthma Basics Presentation – Marillac Social Center; Asthma Community Forum; Asthma Basics Presentation – Malcolm X; and Asthma “Goodie Bag” and Reinforcement of Asthma Management Techniques. Once we made the expansion to all program participants and residents, the number of attendees increased greatly. A total of 268 residents attended these 6 asthma sessions/events. Two sessions are discussed in more detail next. 8 P a g e In late January 2012, an Asthma Community Forum was conducted at the Lawndale Gardens Community Center. The purpose of the forum was to encourage community members to come together and learn about asthma, particularly asthma first aid, through games and discussion. The session was led by the CHW for LG, Kathaleen Hadley. Ms. Hadley created an asthma bingo game for attendees to play, as well as asthma trivia and knowledge quizzes. Some attendees had asthma and some did not, but both groups learned about asthma and how to act in an emergency situation as it is possible for anyone to encounter another (neighbor, family member, friend, etc.) having an asthma attack. Prizes were given to the winners of each activity. On August 10, 2012, HCBT asthma program staff members presented on the basics of asthma at Malcolm X College on Chicago’s Westside. Kim Artis, CHW and Jessica Ramsay, Intervention Coordinator, taught four separate sessions to a total of 75 young adults (age 18-21) attending a career development training program. All attendees lived in the HW housing development. Attendees learned about high rates of asthma in their own community, main triggers of asthma and the importance of always having medication available for use. The consequences of smoking tobacco were also discussed. Trivia questions were asked throughout each session, and prizes were given for correct answers. The group of young adults was very engaged, asked questions and shared personal experiences with asthma. HCBT staff also participated in several community events when asked, such as health fairs to provide educational information on asthma. This helped to foster trusting relationships between the program and community residents as well as raise awareness about the program and asthma management. HCBT staff set up a table with educational materials at the following events throughout the course of the program: Marillac Social Center Weekly Food Pantry; CHA Spring Olympics Event; CHA Operation Warm Coat Drive – 2012 and 2013; Sinai Health System World Asthma Day recognition; Sinai Health System Health Fair; Park Douglas Resident Open House; West End/Jackson Square Health Fair. HCBT’s participation in the CHA Operation Warm Coat Drive was particularly beneficial to CHA residents across the city of Chicago. Ms. Hadley and Ms. Artis provided basic asthma education, information on smoking cessation, and answered questions about asthma for CHA residents from all over the city of Chicago that came by the booth. A total of over 150 residents stopped at the booth and received information. Combined with last year’s event, HCBT staff has served over 250 CHA residents through the CHA Operation Warm event. V. Outside Trainings and Additional Education In order to continue to learn new and helpful information for program participants, HCBT staff took opportunities whenever possible to attend outside trainings and other types of educational sessions relevant to the work conducted by the program. This additional education helped to enhance the services provided to participants enrolled in the program. Table 4 below lists various trainings attended by program staff. Table 4: Trainings attended by HCBT program staff Topic of Training/Educational Session Mental Health Training Smoking Cessation Trainings –American Lung Association (ALA) and Respiratory Health Association (RHA) sessions Safer Pest Control Bed Bugs Training Navigating Uninsured Adults CHW Theater Workshop Chicago CHW Local Network – Various Trainings and Meetings Chicago Asthma Consortium Quarterly Meetings – Various Topics UIC Minority Health in the Midwest Conference Wisconsin Adult Health Literacy Summit Neighborhood Safety Training – Chicago Police Department Attendees HCBT CHWs HCBT CHWs HCBT CHWs HCBT CHWs HCBT CHWs HCBT CHWs, Intervention Coordinator All HCBT Staff All HCBT Staff Kim Artis (CHW), Jessica Ramsay (Intervention Coordinator) All HCBT Staff 9 P a g e At both the American Lung Association (ALA) and Respiratory Health Association (RHA) smoking cessation trainings, in February and March 2012 respectively, CHWs learned valuable information on how to help someone quit smoking, including behavior change methods, use of Nicotine Replacement Therapies (NRTs), and assessing one’s readiness to quit, to name a few. In addition, they received many valuable tools/materials that were then utilized to provide asthma program participants who smoke or who have family members who smoke, with information on smoking cessation. Since smoking and secondhand smoke are among the most common/harmful triggers for children and adults with asthma, having team members trained to provide guidance with smoking cessation to program participants was extremely valuable. This training also allowed us to begin the partnership with the Illinois Tobacco Quitline, previously described in this report. On June 6, 2012, CHWs attended the Bed Bugs training put on by the Safer Pest Control Program in Chicago. Bed bugs were an issue that several of the CHA residents enrolled in the asthma program reported having dealt with in their homes. Many of the residents were not aware of how to take the proper steps towards treating bed bugs and ways to decrease the risk of infestation. After having had this training, CHWs were able to provide more detailed, accurate information to program participants on the issue of bed bugs. VI. Program Outcomes and Findings Figure 2: Breakdown of enrolled participants and those completing the intervention Demographics The demographic data presented here is final and comprised of the total 158 individuals that were consented into the program and completed a baseline home visit. Of these participants, 85 were children and 73 were adults. Four one-time teachings were completed for two adults and two children whose data is not included in the information below. Table 5 displays demographic information and baseline healthcare characteristics for child participants (n=85). Table 6 displays demographic information and baseline healthcare characteristics for adult participants (n=73). Approximately 94% of the children and 92% of the adults enrolled were non-Hispanic Black. The child participants were nearly 52% male and 48% female, while the adult participants were nearly 92% female. The average child participant was 9 years old, and the average adult participant was about 45 years old. 10 P a g e Table 5: Child Participant Demographics and Selected Healthcare Characteristics at Enrollment (N=85) % N Race/Ethnicity non-Hispanic Black 95.3% 81 Hispanic Black 3.5% 3 Puerto Rican 1.2% 1 Gender - % Female ^ Insurance 49.4% 42 92.9% 11.8% 5.9% 79 10 5 9.2 years 85 Mother Grandparent Father Aunt/Uncle 88.2% 8.2% 2.4% 1.2% 75 7 2 1 < High School High School Grad. Some College* College or higher degree 32.9% 29.5% 34.1% 3.5% 28 25 29 3 < $10,000 $10,001-$19,999 $20,000-$29,999 >$30,000 Refused Employment Status of Caregiver Employed full-time Employed part-time Seasonal Disability Unemployed Current Schooling of Caregiver Enrolled in School full-time Enrolled in School part-time Enrolled in a training program Not enrolled in School Relationship Status of Caregiver Married/ committed relationship Single /Divorced/ Widowed / Separated 44.7% 21.2% 10.6% 9.4% 14.1% 38 18 9 8 12 18.8% 14.1% 4.7% 2.4% 60.0% 16 12 4 2 51 10.6% 14.1% 4.7% 70.6% 9 12 4 60 27.1% 72.9% 23 62 Primary Care Physician - % yes Of those with PCP, % knew name of PCP 98.8% 77.3% 84 65 Asthma Specialist in Past 6 months - % yes 11.8% 10 Asthma Action Plan - % yes 25.9% 22 504 Plan - % yes 48.2% 41 Medicaid/Kidcare Medicaid HMO (FHN, Harmony) Private Age (mean) Primary Caregiver Education of Caregiver Household Income ^more than one insurance provider/participant may apply *includes vocational or business school 11 P a g e Table 6: Adult Participant Demographics and Selected Healthcare Characteristics at Enrollment (N=73) % N 91.8% 2.7% 2.7% 2.7% 91.8% 67 2 2 2 67 65.8% 4.1% 2.7% 27.4% 44.5 years 48 3 2 20 72 < High School High School Grad. Some College* College or higher degree Refused 32.9% 30.1% 28.8% 6.8% 1.1% 24 22 21 5 1 < $10,000 $10,001-$19,999 $20,000-$29,999 >$30,000 Don’t Know Refused 38.4% 24.7% 13.7% 4.1% 16.4% 2.7% 28 18 10 3 12 2 Employed full-time Employed part-time Seasonal/Day Labor Employment Disability Self-employed Unemployed 12.3% 6.8% 1.4% 9.6% 1.4% 68.5% 9 5 1 7 1 50 Enrolled in School full-time Enrolled in School part-time Not enrolled in school Relationship Status Married/ In committed relationship Single /Divorced/ Widowed / Separated Refused 5.5% 19.2% 75.3% 4 14 55 15.1% 83.6% 1.4% 11 61 1 Primary Care Physician - % yes 78.1% 57 Asthma Specialist in Past 6 months - % yes 8.2% 6 Asthma Action Plan - % yes 5.5% Race/Ethnicity non-Hispanic Black Puerto Rican Non-Hispanic White Other Gender - % Female Insurance Medicaid/ Medicare Medicare HMO/Private No Insurance/Self Pay Age (mean)^ Education Income Employment School 4 * Includes vocational or business school ^ 1 missing 12 P a g e 1. Decrease asthma-related morbidity (Primary Objective) In order to measure how effective the HCBT program was at achieving the first primary objective of decreasing asthma-related morbidity, progress was measured towards 3 sub-objectives: (a) to decrease the frequency of asthma symptoms; (b) to decrease urgent health resource utilization; (c) to decrease activity-limited days. This data is presented in Table 7-Figure 3. Symptom frequency, asthma severity and health resource utilization data was collected via a monthly follow-up form. This form was completed during phone encounters and/or home visits. The findings presented below are limited to the 55 (81% of those enrolled) adults and 60 (71% of those enrolled) children who completed the entire intervention period (6 months for adults and 12 months for children). a. Decrease frequency of asthma symptoms (Sub-Objective) As can be seen in Table 7 below, children’s daytime symptom frequency decreased from a mean of 4.1 days over the 2-week period preceding the baseline visit, to an average of 0.8 days over 2-weeks over the course of twelve months of follow-up phone calls/visits. Nighttime symptom frequency among children also decreased from a mean of 3 days over 2-weeks at the time of the baseline visit, to a mean of 0.8 over 2-weeks over the course of twelve months of followup phone calls/visits. Adult participants saw a 60% decrease in daytime symptoms. In addition, adult participants’ use of their quick relief medication was reduced from an average of 4.2 times over 2-weeks at the time of the baseline visit, to an average of 2.6 times over two weeks over the course of the six month follow-up period (Table 8). Table 7: Children Symptom Frequency in the past 2 weeks at Baseline vs. average during follow-up year (n=59)^ Daytime Symptoms Nighttime Symptoms Days Needed Rescue Meds Mean Median Range Mean Median Range Mean Median Range Baseline Follow-up Period 4.1 2.0 0-14 3 1.0 0-14 3.1 0.0 0-14 0.8 0.6 0-6 0.8 0.5 0.52 0.9 0.5 0-5.7 p-value* % change 0.0001 80.5% 0.06 73.3% 0.02 71.0% ^1 missing *Wilcoxon signed-rank non-parametric test used to assess statistical significance Table 8: Adult Symptom Frequency in the past 2 weeks at Baseline vs. average during follow-up year (n=55) Follow-up Baseline p-value* % change Period Daytime Symptoms Nighttime Symptoms Days Needed Rescue Meds Mean Median Range Mean Median Range Mean Median Range 5.0 3.0 0-14 3.5 1.0 0-14 4.2 2.0 0-14 2.0 1.3 0-9.3 2.3 1.0 0-14 2.6 1.8 0-10 0.0001 60.0% 0.06 34.3% 0.02 38.1% *Wilcoxon signed-rank non-parametric test used to assess statistical significance 13 P a g e b. Decrease urgent health resource utilization (Sub-Objective) An important indicator of a participant’s level of asthma control is their utilization of urgent health resources, including Emergency Department visits (ED), hospitalizations and urgent clinic visits. Table 9 illustrates the impact that HCBT had on child participants’ urgent health resource utilization. Findings suggest that the program is associated with an 83% decrease in ED visits among child participants, and a 50% reduction in hospitalizations. When urgent health resource utilization is considered collectively, the average child went from being seen in the ED, hospitalized or visiting an urgent care center 3.3 times on average over the year prior to the program to only 0.8 times in the year following the intervention. Table 9: Asthma-Related Health Resource Utilization in the Year Prior to Baseline vs. Year Following for Children (N=59)^ ED Visits Hospitalizations Hospital Days Clinic Visits – Urgent Clinic Visits – Regular Sum Urgent HRU** Mean Median Range Mean Median Range Mean Median Range Mean Median Range Mean Median Range Mean Median Range Baseline Follow-up Period 2.4 0 0-96 0.4 0 0-2 0.8 0 0-7 0.5 0 0-7 2.3 2 0-12 3.3 1 0-98 0.4 0 0-8 0.2 0 0-5 0.2 0 0-6 0.3 0 0-4 2.1 2 0-7 0.8 0 0-14 p-value* % change 0.001 83.3% 0.01 50.0% 0.005 75.0% 0.4 40.0% 0.7 8.7% 0.003 75.8% ^1 missing *Wilcoxon signed-rank non-parametric test used to assess statistical significance ** Sum of urgent health resource utilization variables (hospitalizations, ED visits and urgent clinic visits) Table 10 and Figure 3 illustrate adult participants’ health resource utilization at baseline and in the six-month follow-up period. When all adult participants who completed the intervention (n=55) are evaluated collectively, we see a 39% decrease in ED visits and a 24% decrease in urgent health resource utilization as a whole. However, since many adult participants were uninsured and therefore not frequent utilizers of health services at enrollment, their data is further evaluated in a slightly different fashion. Figure 3 shows the urgent health resource utilization among adults who presented at baseline with uncontrolled asthma (defined as having daily or nightly asthma symptoms, or having utilized at least two urgent health resources in the year preceding baseline). When considering the cohort of adults with uncontrolled asthma, the proportion who had any ED visits decreased by 44% between baseline and the end of the intervention. Similarly, though 81.3% of adults with uncontrolled asthma at baseline had utilized some form of urgent health resources in the year prior to the baseline visit, only 25% reported doing so over the follow-up period. 14 P a g e Table 10: Asthma-Related Health Resource Utilization in the Year Prior to Baseline vs. Year Following^ in Adult Participants (N=55) Baseline ED Visits Hospitalizations Hospital Days Clinic Visits – Urgent Clinic Visits – Regular Sum Urgent HRU** Mean Median Range Mean Median Range Mean Median Range Mean Median Range Mean Median Range Mean Median Range 1.4 0 0-10 0.4 0 0-5 1.3 0 0-14 0.2 0 0-4 2.9 1 0-18 2.1 1 0-11 Follow-up Period 0.9 0 0-16 0.3 0 0-10 1.7 0 0-60 0.4 0 0-8 2.2 2 0-10 1.6 0 0-32 p-value* % change 0.05 39.2% 0.06 34.1% 0.19 -33.6% 0.38 -81.8% 0.4 24.1% 0.004 23.8% ^6 months of data projected out to represent one year *Wilcoxon signed-rank non-parametric test used to assess statistical significance ** Sum of urgent health resource utilization variables (hospitalizations, ED visits and urgent clinic visits) ¥ Figure 3: Percentage of Adult Participants with Uncontrolled Asthma who Experienced any ED visits and Urgent Health Resource Utilization at Baseline compared to 6-months (N=32) 100.0% 81.3% Baseline 80.0% 65.6% 6 Months 60.0% 40.0% * 21.9% ** 25.0% 20.0% 0.0% ED Visits Sum Urgent HRU^ * Chi-square 14.3, p<0.001 ** Chi-square 20.33, p<0.001 ¥ Uncontrolled asthma defined as having daily or nightly asthma symptoms, daily rescue medication use, or having utilized at least two urgent health resources in the year preceding baseline ^ Sum Urgent Health Resource Utilization (HRU) = sum of all ED Visits, Hospitalizations, and urgent clinic visits due to asthma c. Decrease Activity Limited Days (Sub-Objective) The children who completed the twelve-month program reported, on average, having 7.9 activity limited days in the year prior to the intervention. Over the course of the intervention year, children completing the intervention reported 1.7 activity limited days due to their asthma. In other words, there was a 78.5% reduction in activity limited days for children completing HCBT. Adults self-reported approximately 7 activity limited days, on average, in the year 15 P a g e preceding the intervention. Adults did not experience an improvement in activity limited days following the completion of the 6 month intervention. This data has not yet been analyzed for the subsample of adults with uncontrolled asthma, and it is likely that cohort will have experienced an improvement in this outcome. 2. Improve Family’s Quality of Life (Primary Objective) The quality of life (QOL) of the child’s primary caregiver was assessed using the Pediatric Asthma Caregiver’s Quality of Life Questionnaire (PACQLQ), a validated and extensively used instrument.1 The tool yields three scores: an overall score, an activity limitation sub-score and an emotional function sub-score. In each case, the maximum possible score is seven and a change of 0.5 or more has been shown to be clinically significant.2 The overall QOL score and the emotional function sub-score for caregivers of children enrolled in HCBT significantly increased (0.7 and 0.8 point, respectively) between baseline and the twelve-month follow-up (Figure 4). The activity limitation sub-score also significantly increased 0.6 point (from 5.9 to 6.5) between baseline and the twelve-month follow up. There were 42 caregivers that completed this questionnaire at baseline and at the completion of the intervention. Figure 4: Pediatric Asthma Caregiver’s Quality of Life (N=42)^ 7 6 5 * * 6.1 * 6.5 5.9 5.4 5.9 5.1 4 Baseline 3 12 Months 2 1 0 Overall Score Activity Limitation Domain Emotional Function Domain ^This tool is collected once per household * Statistically significant difference (p<0.05) per Wilcoxon signed-rank non-parametric test. A 0.5 point change is also clinically significant Similar to the PACQAQ, the Asthma Quality of Life Questionnaire (AQLQ) was administered to adults enrolled in our program.3 This questionnaire asks questions regarding four domains (symptoms, activity limitation, emotional function and environmental stimuli). As with the PACQLQ, the maximum possible score is seven and a change of 0.5 or more has been shown to be clinically significant.3 As shown in Figure 5, the QOL symptom sub-score was 1.0 point higher for adults at the six-month follow-up than at baseline (from 4.4 to 5.4). The Emotional Function sub-score significantly increased 1.3 points, from a score of 4.5 at baseline to a score of 5.8 at the end of the intervention. The overall QOL score for adults significantly increased from an average of 4.7 to 5.6 over the six-month period. 1 Juniper EF, Guyatt GH, Feeny DH, et al. Measuring Quality of Life in Parents of Children with Asthma. Quality of Life Research 1996; 5: 27-34. 2 Juniper EF, Guyatt GH, Willan A, Griffith LE. Determining a Minimal Important Change in a Disease-specific Quality of Life Questionnaire. J Clin Epidemiol. 1994; 47(1):81-87. 3 Juniper EF, Buist AS, Cox FM, et al. Validation of a Standardised Version of the Asthma Quality of Life Questionnaire. Chest 1999; 115:1265-1270. 16 P a g e Figure 5: Asthma-related Adult Quality of Life (N=51) Baseline 6 Months 7 * 6 5 4 * 5.6 4.7 5.4 * * 5.5 5.8 4.8 4.4 * 5.3 5.7 4.5 3 2 1 0 Overall Score Symptom Domain Environmental Domain Emotion Domain Activity Domain * Statistically significant difference (p<0.05) per Wilcoxon signed-rank non-parametric test. A 0.5 point change is also clinically significant 3. Decrease Asthma Triggers (Intermediate Objective) An intermediate objective of HCBT was to reduce the number of asthma triggers that children are exposed to within their homes by improving the home environment and reducing exposure to tobacco smoke. As discussed earlier, in the “Tasks and Activity Assessments” portion of this report, many participants reported issues within their homes that were then resolved. Table 11 shows the percentage of children who had a specific observed trigger present in their home at baseline, along with the proportion of those with the trigger present at baseline that were able to eliminate the trigger by the 12-month follow-up. For example, of the 6 children who had noticeable mold/mildew in their home at baseline, only 1 still had mold/mildew in their home at the time of the 12 month follow-up. In other words, 83% of children with mold/mildew in their home at baseline had the issue resolved by 12-months. As another example, 100% of the child participants’ homes that had evidence of mice at baseline no longer had mice by the end of the intervention. In fact, there were reductions of 37.5%-100% across the six triggers examined. Table 11: Presence of Six Home Triggers as Observed During the Home Evaluation Assessment at Baseline and 12-Month Followup for Child Participants (n=53) Smoke no yes Furry Pets no yes Mold/Mildew no yes Mice no yes Roaches no yes Dust no yes Baseline % yes at BL 12M* % yes at BL who became NO at 12M 45 8 15.1% 3 5 37.5% 46 7 13.2% 4 3 57.1% 47 6 11.3% 5 1 83.3% 47 6 11.3% 6 0 100% 43 10 18.9% 6 4 60.0% 53 0 0.0% n/a n/a * Limited to those with visible evidence of the trigger at baseline. 17 P a g e Table 12: Presence of Six Home Triggers as Observed During the Home Evaluation Assessment at Baseline and 6-Month Follow-up for Adult Participants (n=54) Baseline % yes at BL 6M* % yes at BL who became NO at 12M 42 12 22.2% 5 7 41.6% 42 12 22.2% 5 7 41.7% 43 11 20.4% 8 3 72.7% 44 10 18.5% 7 3 70.0% 45 9 16.7% 5 4 55.6% 48 6 11.1% 5 1 83.3% Smoke no yes Furry Pets no yes Mold/Mildew no yes Mice no yes Roaches no yes Dust no yes * Limited to those with visible evidence of the trigger at baseline. As can be seen in Table 12, 42% of adult participants who had evidence of tobacco smoke in their house during the baseline home walk-through, were able to use the resources provided to eliminate tobacco smoke from their home by the end of the six-month intervention. Additionally, 83% of adults who had very noticeable dust present in their home at baseline no longer had high levels by their 6-month home visit. In fact, there were reductions of 41.6%-83.3% across the six triggers examined. 4. Improve Asthma-related Knowledge (Intermediate Objective) An Asthma Knowledge Quiz, consisting of 17 multiple choice and true/false questions, was administered to each adult and child’s caregiver at baseline, 6 month follow-up, and 12-month follow-up (for child participants). The quiz asks objective questions to test the caregiver’s or adult participant’s comprehension of the education portion of the intervention as well as what they already know about their asthma (e.g., True or False: “Quick relief medicine is a rescue medicine for asthma. It should be given only when you have symptoms of asthma.”). Figure 6 illustrates the improvement in asthma-related knowledge among the participants. Adult participants improved their scores by an average of 1.3 points between the baseline and 6-month visits (p<0.05), while the caregiver’s of child participants increased their knowledge scores by 2.5 points between the baseline and 12-month visits (p<0.05). Figure 6: Asthma Knowledge Quiz Scores^ for Adults and Children’s Caregivers at Baseline and Follow-up 17 15 * 14.8 13.5 15 * * 15.5 6M 12M 13 13 11 9 7 5 3 1 BL 6M Adult (n=48) BL Child (n=30) ^Maximum score of 17 points *p<0.0001; Wilcoxon signed-rank non-parametric test used to assess statistical significance 18 P a g e 5. Improve use of an Asthma Action Plan (Intermediate Objective) Figure 7 outlines the efforts that the Community Health Workers made in creating an Asthma Action Plan (AAP) for each participant. As mentioned earlier in this report, the CHW worked with the participant to schedule a visit with their PCP in order to get updated asthma medication prescriptions if they did not have their medications present in the home. While only 7% of adults enrolled in HCBT had an AAP at baseline, 85% had a completed AAP by the end of their six-month intervention. Similarly, 75% of children who completed the 12-month intervention had a completed AAP by their final follow-up. Figure 7: Percentage of Adults and Children with an Asthma Action Plan at Baseline and at the end of the intervention 100% 85% 75% 80% 60% 40% 20% 0% 27% 7% BL 6M Adults (n=54) BL 12M Children (n=60) 6. Additional Evaluation A cost-savings analysis was also completed for the HCBT project and yielded positive results. Overall, for every one dollar spent on the project, the health care system saved two dollars. Additionally, a total of eight hundred dollars in asthma-related health care services were saved per child that participated in the program. Throughout the course of the intervention, several participants wrote letters to the program and their CHW, expressing their gratitude for being a part of the program as well as what they had learned and accomplished throughout the intervention. These serve as a great testament to the accomplishments of the CHWs in empowering program participants. Two of these letters can be found in Appendix D. VII. Dissemination On Saturday, June 29, 2013 an end-of-program event was held to thank all program participants and to celebrate the successes of the program. The event was held in a nearby park in partnership with CHA. Another purpose of the event was to present program findings back to participants as well as to allow for participant testimonials. Program CHWs presented preliminary program outcomes, with seven program participants providing testimonials about their experiences in the program and what they learned over the course of the intervention. Because the testimonials were so powerful, but staff did not have the ability to videotape them at the event, participants were asked to recreate their testimonial on video and gave their consent to allow it. CHWs went to the homes of five of the participants that gave testimonials in order to capture them on video, and we had a professional put the testimonials and other program photos into a video format. The video is available for your viewing at the following link: http://www.youtube.com/watch?v=ngwNjrOfRiI. In addition, photos from the event can be found in Appendix E. Throughout the course of the program, several opportunities arose to disseminate information about the HCBT program at conferences, forums and meetings. Presentations that were made by HCBT staff are outlined in Appendix F. The HCBT program was also featured in the August 2013 edition of The American Public Health Association newspaper, The Nation’s Health. The article prominently features the story of CHW, Kim Artis, and the program’s outstanding work in Chicago public housing. A copy of the article is included as Appendix G. Principal Investigator, Helen Margellos-Anast, and Project Director, Melissa Gutierrez recently prepared a manuscript summarizing key findings from Sinai’s six asthma interventions to date, including HCBT. The article is now 19 P a g e out for review. We also plan to write-up the final outcome data in a publishable manuscript. We will be working on this in the coming year and will share this information with HUD as it becomes available. VIII. Conclusions and Lessons Learned We are pleased that the Helping Children Breathe and Thrive project has successfully met all of the grant requirements, having addressed obstacles and seized opportunities as they arose via protocol modifications. As is evident when considering the outcomes realized, progress was made towards all of our objectives. As such, we are confident that we have made a sizeable impact on the health and well-being of the community served by the program. Key outcomes associated with the main objectives include: decreased frequency of asthma symptoms, reduced number of asthma triggers in the home environment, and improved use of an Asthma Action Plan. Children decreased daytime asthma symptoms by 81% (see page 13). Adult daytime asthma symptoms decreased by 60%. Additionally, 83% of children and 73% of adults, who had evidence of mold in their home at baseline, no longer had mold in their home at the end of the intervention. Finally, the percentage of adults with an AAP increased by 78%, while the percentage of children with an AAP increased by 48% (see page 19). There were several overall lessons learned via the implementation of the HCBT project. First, many longstanding lessons about CHWs were reconfirmed. CHWs quickly and effectively establish relationships of trust with the families they serve, which is essential to the success of the intervention. Additionally, effective CHW hiring and training processes continue to prove essential for CHWs to effectively deliver comprehensive asthma education in the community. In the same light, continual support and mentoring for CHWs throughout the project is vital, as CHWs encounter many challenging situations in the field. CHWs are hired for skills that only they can bring and that cannot be taught, such as cultural sensitivity, community connections, and an intricate knowledge of the communities being served and their needs. Other skills such as completing paperwork correctly, computer skills and managing a case load are areas in which CHWS may need more support and that can be developed with the support and guidance of a supervisor. In regards to program participants, one of the main challenges encountered concerns the economic hardship faced by the majority of them as well as competing priorities. The cost of healthcare services and medications is very high, and not only do many participants not have the money to put towards consistently seeing the doctor and having medications on hand, they often have other things to pay for that they view as more pressing (e.g., child care, food and utility bills). Another challenge that was often faced with child participants is multiple caregivers. Several children stayed with two or three different caregivers throughout the week, which posed a challenge in establishing a consistency in managing their asthma. For example, these children and/or their caregivers were more likely to report that they left their medication at another caregiver’s house so they were not able to take it for one or more days, etc. Compliance in implementing behavior change was also an on-going challenge. One example of this concerns smoking cessation, a challenging proposition for many participants. Instead of making the immediate goal to quit smoking completely, we have learned to first work towards reducing the number of cigarettes per day and encouraging participants to smoke outside of the home. These are more attainable short-term goals that may ultimately be a step towards cessation. Asthma medication adherence is also frequently associated with many barriers, such as inability to consistently have medication available due to financial constraints and/or a lack of health insurance, fear of medication side effects, and simply not making it a priority/forgetting. In regards to making home improvements, it is important to note that management companies already have a process in place for modifications. Working directly with management company staff to integrate program referrals into their established system was very effective in helping participants to resolve asthma-related housing issues. Another important lesson learned concerns collaboration with project partners. Successful and effective collaboration takes time and commitment. Specifically, fine tuning collaborative efforts should be a transparent process, with all parties being kept abreast of any changes that have been made. Collaboration requires learning a new “language” as well as new systems, and finding key partners to work with is essential to the success of a project. Based on our continual analysis of recruitment activities, we learned as we went along and made changes to optimize our outreach and referral processes via the collaborative strategies discussed throughout this report. Lastly, careful planning for structured communication and meeting regularly with partners is very important, especially in the early stages of a project. Leveraging established processes and persons is also a key to a successful collaboration, along with open and thorough communication from the onset. All parties involved in the collaboration should remain sensitive to 20 P a g e the individual needs of the residents/participants being directly served by the program, while also being sure to follow established protocols. Continual acknowledgement of all team members’ contribution is always important. Our experience working with adults suggests that a 12-month intervention may be more effective than a 6month intervention. As previously mentioned, many of the adult participants did not have insurance, had no recent doctor appointment and/or no medications, in addition to other issues which take time to address and require persistence on the part of the CHW. Overall, most adult participants were very much in need of the intervention and therefore would have likely found the longer intervention even more beneficial. The new grant that we have received from HUD will allow us to fully develop and test the CHW model in adults with asthma through a 12 month intervention. This project will utilize much of the same staff and maintain Sinai’s working relationship with CHA. In conclusion, the HCBT project was successful in meeting its objectives, as well as navigating many challenges along the way. As a result, we have learned valuable lessons for on-going program improvement and successful collaboration with key partners. As mentioned previously in Section VII (Dissemination), several presentations on the HCBT program have been made and articles have been written. Both have garnered substantial interest from various audiences. Principal Investigator, Helen Margellos-Anast, and Project Director, Melissa Gutierrez have submitted an article for publication summarizing Sinai’s six asthma interventions, including some outcome data from the HCBT project and are waiting to hear back concerning its acceptance. Moving forward, we plan to write-up the final outcome data in a publishable manuscript. We will be working on this in the coming year and will share this information with HUD as it becomes available. Also as mentioned above, we put together a video of testimonials from HCBT program participants, which can be seen here: http://www.youtube.com/watch?v=ngwNjrOfRiI. Sinai Asthma Program staff is looking forward to kicking off the new HUD-funded project, entitled Helping Chicago’s Westside Adults Breathe and Thrive, which is slated to begin November 1, 2013. The opportunity to implement and more formally test the CHW asthma intervention with adults directly stems from the successes of the HCBT project, and we are thrilled to be able to continue to serve adults with poorly controlled asthma living in Chicago’s under-served Westside communities. 21 P a g e Appendix A Sinai Asthma Program CHW Asthma Education Evaluation Tool Level 3 Results: CHW: Evaluator: Date: Time: Guidelines: CHW must at least meet requirements in each area below in order to be prepared to begin actual home visits (with supervisor present). For this role play, it is preferred that the CHW exceed requirements or better. This role play is designed to assess CHWs overall ability to recall and teach each aspect of asthma in a detailed manner, further building upon what was required in the Level 2 role play. It is to be completed during the week before going out on an actual program home visit. Scenario for Level 3 role play: Person who is being educated during the role play is to make up an age of the child or adult being taught, as well as medications that child or adult is currently taking. This scenario should include some “twists” i.e. participant may have several controllers and/or relievers, both nebulizer and inhaler, child using inappropriate device/medication for his/her age, etc. in order to simulate a more realistic situation. This will also allow for the assessment of CHWs full, well-rounded understanding of asthma management. Time: 2 hours or less Please fill out the following evaluation and pay close attention to the expectations for “meet requirements”. 1. Communication Skills Criteria for “meets requirements”: • Animated (for visual learners especially children, acting-out what you are teaching) • Friendly • Greet all family members/others present at the visit • Introduce oneself and explains role • Speak clearly and at a moderate pace • Observe study participant’s body language and signs of understanding • Demonstrate listening skills • Make teaching conversational!! 1 Poor 2 Fair 3 4 5 Meets Exceeds Exceptional Requirements Requirements Comments: 2. Asthma Knowledge/Instruction on Asthma Basics Criteria for “meets requirements”: ***MUST use appropriate visual tools during explanation of what asthma is – i.e. show normal v. asthmatic airway, etc. • Ask “Can you tell me what you know about asthma?” and listens carefully to participant’s answer • Based on participant’s answer, explain 1 Poor Comments: 2 Fair 3 4 5 Meets Exceeds Exceptional Requirements Requirements • • • • 3. what asthma is (basic): o Chronic inflammation of airways o Disease that is not curable but controllable Name signs/symptoms of asthma that can be heard and/or felt, stating all 4 of the following: o Coughing o Wheezing o Shortness of Breath o Chest Tightness Explain what goes on inside the airways, that cannot be heard and/or felt: o Mucous o Swelling/Information o Redness Explain consequences of uncontrolled asthma: o Airway remodeling o Frequent ER visits o Death (in extreme cases) Emphasize that when controlled, both adults and children can lead normal, active lives Knowledge of Triggers Criteria for “meets requirements”: 1 Poor • Explain what a trigger is • Name main asthma triggers: o Cigarette Smoke o Change of Weather Comments: o Strong Odors o Cold & Flu o Pets • Name other common triggers/allergens: o Mold o Dust Mites o Cockroaches o Humidity o Exercise o Strong Emotion o Air Pollution • Ask participant if has noticed any of these triggers affecting their/their child’s asthma • Explain several ways to avoid each trigger • Demonstrate knowledge of what to look for and where in home assessment (mock home assessment?) 2 Fair 3 4 5 Meets Exceeds Exceptional Requirements Requirements 4. Knowledge of Medications Criteria for “meets requirements”: • Ask participant “What medications are you currently taking?” • Correctly identify participant’s medications as quick-relief or controller • Explain 2 types of medications: o Reliever/Quick-Relief o Controller • Explain role of reliever/quick-relief: o To be used AS NEEDED o RELIEVES “noisy” part of asthmacoughing, wheezing, loosens muscles around airway to open up o CARRY with you at ALL TIMES o Exercise Induced Asthma – use quick-relief 30 minutes before playing sports or exercising to open up airways. Explain that this is still temporary opening of airways, NOT a controller of underlying symptoms • Explain role of controller : o To be used EVERYDAY o CONTROLS parts of asthma you can’t see or hear: inflammation, swelling, redness, mucous o PREVENTS asthma attacks from occurring 5. 1 Poor 2 Fair 3 4 5 Meets Exceeds Exceptional Requirements Requirements 2 Fair 3 4 5 Meets Exceeds Exceptional Requirements Requirements Comments: Use of Devices Criteria for “meets requirements”: ***MUST be prepared with all necessary devices organized and laid out in front for teaching • Based on participant’s medications, select appropriate devices to teach the use of: MDI w/ Spacer: • Verify that device is appropriate for age of participant • Provide correct handout to participant • Must teach all 8 steps correctly: o Shake inhaler for 10 seconds o Remove cap from spacer and inhaler o Insert inhaler in back of spacer appropriately (slit at the top) o Exhale normally o Place spacer mouth piece in the 1 Poor Comments: mouth, behind the teeth and seal lips tightly o Spray once and breathe in DEEPLY and SLOWLY o HOLD breathe and count to 10 o Exhale ** Explain that each puff is done separately, repeat steps to take additional puff(s) ** Explain that if spacer makes a whistling noise, it indicates person is breathing in too fast and needs to take a slow down MDI w/ Spacer and Mask • Verify that device is appropriate for age of participant • Provide correct handout to participant • Must teach at least all 7 steps correctly: o Shake inhaler for 10 seconds before each puff o Insert inhaler in back of spacer appropriately (slit at the top) o Proper placement of face mask on the face, emphasizing the need for good seal o Explain that child needs to keep face mask on face until 5 breaths are taken o Explain how to assess that 5 breaths have been taken o Each puff to be taken separately **Explain that child is not to be moving the face, crying or talking during treatment **Explain that if spacer makes a whistling noise, it indicates that child is breathing in too fast and needs to slow down Diskus • Verify that device is appropriate for age of participant • Provide correct handout to participant • Must teach at least all 9 steps correctly: o Open the Diskus o Click the Diskus open o Turn head away from Diskus opening and breathe out before using the Diskus o Place Diskus in mouth properly (beyond the teeth, lips sealed around the mouthpiece) o FAST and DEEP inhale o Hold in breathe for 5-10 seconds at the end of inhalation 1 Poor 2 Fair 3 4 5 Meets Exceeds Exceptional Requirements Requirements 2 Fair 3 4 5 Meets Exceeds Exceptional Requirements Requirements Comments: 1 Poor Comments: o o o Close Diskus after each use Show how to track the dosage of the Diskus Explain to rinse mouth out with water after use Turbuhaler • Verify that device is appropriate for age of participant • Provide correct handout to participant • Must teach at least all 10 steps correctly: o Open the Turbuhaler o Twist and click back the Turbuhaler o Breathing out before using the Turbuhaler o Proper placement of Turbuhaler in the mouth (beyond the teeth, lips sealed around the mouthpiece) o FAST and DEEP inhale o Hold in breathe for 5-10 seconds at the end of inhalation o Close Turbuhaler after each use o Show how to track the dosage of the Turbuhaler o Repeat steps for additional doses o Explain to rinse mouth out with water after use Twisthaler • Verify that device is appropriate for age of participant • Provide correct handout to participant • Must teach at least all 10 steps correctly: o Open the Twisthaler o Breathe out away from opening before using the Twisthaler o Proper placement of Twisthaler in the mouth (beyond the teeth, lips sealed around the mouthpiece) o FAST and DEEP inhale o Hold in breathe for 5-10 seconds at the end of inhalation o Close Twisthaler after each use o Show how to track the dosage of the Twisthaler o Repeat steps for additional doses o Explain to rinse mouth out with water after use 1 Poor 2 Fair 3 4 5 Meets Exceeds Exceptional Requirements Requirements 2 Fair 3 4 5 Meets Exceeds Exceptional Requirements Requirements Comments: 1 Poor Comments: Nebulizer • Verify that device is appropriate for age of participant • Provide correct handout to participant • Must teach at least all 9 steps components: o How the various components are to be connected o Differentiate between disposable and reusable nebulizer cup o Show where medication needs to be placed in nebulizer o Demonstrate knowledge of duration for which disposable and reusable cup are to be used o Properly determine if a child should use treatment using face mask or mouthpiece o Explain that nebulizer treatment is not to be given by the blow by method o Explain periodic tapping of the nebulizer cup o Explain how to monitor the air filer in the compressor o Explain that for those who have the skill set, using an MDI with a spacer is just as effective as a nebulizer when used correctly 1 Poor 2 Fair 3 4 5 Meets Exceeds Exceptional Requirements Requirements Comments: Cleaning Devices: o CHW must now be able to explain the appropriate way to clean each device Total score: ______________ / Total # of competencies: ____________ • =Average/Overall performance score: __________ Overall “Level 3” Knowledge, Teaching and Communication Skills: 1 Poor 2 Fair 3 Meets Requirements 4 Exceeds Requirements 5 Exceptional Additional Comments: Next Steps: Upon Successful Completion of this Role Play: CHW receives certificate (if applicable), ready to go on home visits If does not meet requirements: Based on feedback from evaluator, repeat role play as soon as possible until requirements are met to go on home visit Appendix B Sinai Asthma Program Community Health Worker Field Evaluation Tool Guidelines The Community Health Worker (CHW) shadow and evaluation process is for quality assurance purposes; to ensure that the CHW is continuing to deliver the correct information to clients, according to protocols found in the Community Health Worker Asthma Education Manual and the Community Health Worker Home Visit Education Protocol. The main goal of this evaluation is to ensure that CHWs are tailoring the asthma education to the needs of the participants, as this is an overarching goal of the Sinai Asthma Program. CHWs are expected to be including all accurate asthma education information in each visit (at this point, CHW should have mastered all asthma information from previous trainings and have at least 2-3 months experience in the field). If the evaluator is unsure if all information is being presented in an accurate manner, please refer back to Community Health Worker Role Play Evaluations: Levels 1, 2 and 3. All CHWs are to be shadowed by their supervisor every 2-3 months on at least one randomly selected home asthma education visit. For those CHWs with only 1-2 years work experience, they may be shadowed on more than one home visit to assess competencies on the two different home visits (e.g., with a home assessment and without). The following evaluation should be filled out for each visit that a CHW is shadowed. Select the appropriate evaluation section, depending on the type of visit you are observing. For each competency, please evaluate the CHW on the scale of 1-5 and take notes in the provided area. At the end of the evaluation, please total the scores for all competencies and write it in the appropriate box below each evaluation section. Average the evaluation score, and circle the overall results on the scale of 1-5. Do not round up or down, use the raw calculated score. Make any additional notes. Overall scores below 3.0 (“Meets Requirements”) If the overall score on the first field evaluation falls between 2.0-2.9 (Fair): o CHW meets with direct supervisor in order to discuss specific areas where improvement is needed o Areas of improvement are documented and signed off on by CHW and supervisor o CHW is evaluated in the field a 2nd time within the next two weeks o If the overall score still remains below a 3.0 on the 2nd field evaluation: CHW will be pulled out of the field in order to undergo additional review/training as well as discuss where the problem lies and take appropriate actions to find a solution If the overall score on the 1st field evaluation falls at 1.9 or below (Poor): o CHW will be pulled out of the field in order to undergo additional review/training as well as discuss where the problem lies and take appropriate actions to find a solution Baseline Visits: Notes: 1. CHW is prepared for visit with any and all materials that may be needed. This is imperative. 1 Poor 2 Fair 3 Meets Requirements 4 Exceeds Requirements 5 Exceptional N/A (Explain in notes section) 2. CHW is clearly observing participant’s body language, ability to understand information given, and in turn gauging how much education should be delivered at this visit. 1 Poor 2 Fair 3 Meets Requirements 4 Exceeds Requirements 5 Exceptional N/A (Explain in notes section) 3. CHW has made every effort to engage participant in the teaching; CHW is not only one talking/lecturing (ask questions, etc). 1 Poor 2 Fair 3 Meets Requirements 4 Exceeds Requirements 5 Exceptional N/A (Explain in notes section) 4. CHW asks participant to demonstrate usage of medication/devices. This must happen before CHW conducts a return demonstration, in order to assess knowledge and complete the Medication and Evaluation of Technique data tool. 1 Poor 2 Fair 3 Meets Requirements 4 Exceeds Requirements 5 Exceptional N/A (Explain in notes section) 5 Exceptional N/A (Explain in notes section) 5. Proper trigger avoidance techniques addressed. 1 Poor 2 Fair 3 Meets Requirements 4 Exceeds Requirements 6. Emphasis of relevant weather based triggers (based on weather at time of visit). 1 Poor 2 Fair 3 Meets Requirements 4 Exceeds Requirements 5 Exceptional N/A (Explain in notes section) 7. By the end of this visit, CHW has made very clear at a minimum*: a. What asthma is b. Roles of medications and when to take each (controller v. quick relief) c. Importance of keeping medications available at all times d. What to do in an emergency situation 1 Poor 2 Fair 3 4 5 N/A Meets Exceeds Exceptional (Explain in Requirements Requirements notes section) *More will be taught if patient demonstrates good understanding of material and seems able to retain more information at this visit. Total: ______________ Appendix C Participant Asthma Action Plan Tracking Further description of flow chart: A total of 43 participant AAPs were not signed and returned. The reasons for AAP not being signed and returned, as outlined in the flow chart above are: • • • • • Doctor did not return: After several follow up calls by HCBT staff, PCP office did not fax back the signed copy. No recent doctor visit: Physician or clinic staff communicated to HCBT staff that they would not return signed AAP because patient did not have a recent enough visit with this doctor. Lost to follow up: After faxing the AAP, patient was lost to follow up and AAP was not returned. Doctor refused: Physician or physician’s office refused to collaborate. No clinic record of patient: After faxing AAP, physician office called and said they had no record of this patient at this office. A total of 36 participant AAPs were not faxed. The reasons for not having faxed the AAPs, as outlined in the flow chart above are: • • • • • No doctor: Participant did not have a regular doctor to fax AAP to. Lost to follow up: Participant was lost to follow up before AAP was faxed to physician. No recent doctor visit: Participant notified CHW that they had not been to their PCP in over a year. One time teaching: Participant received one home visit and AAP is not faxed for these visits. Patient refused: Participant stated they did not want HCBT staff in contact with their physician. Appendix Participant Letters Participant Letter 1 -522? i gt Kk ?:74 ?neT-amnn Ila mm aim I i 3% El?ea . :3 air ttiif-ft??; .Jmma%mm at iiaiwtmmawemti ?wig I.-, II: an trig; Participant Letter 2 "How the Asthma Program and CHW Kim has Blessed Ms. Serah's Life" There are so many beautiful things I can say about CHW Kim. Number one, I believe she is truly made to be in the field of health care. God has truly blessed Kim with the gift of being an excellent CHW. Kim is a very caring, kind and gentle person. CHW Kim can be very firm and convincing when asking me to do things pertaining to my health. I made all the excuses in the world about going to the doctor and taking care of myself, before I joined the asthma program and meeting CHW Kim. This program and Kim opened my eyes about taking care of my health. I now go to the doctor every month, and I take my Meds as prescribed. My health is so much better, and I am feeling better than I have felt in a long time. I am also able to manage my asthma so much better. I have learned an extreme amount of information from this program. I now use more green products in my home to clean, which helps with controlling my asthma. I just want to say thank you to the asthma program for the knowledge I have gained about asthma. Most of all I would like to thank Kim for her gift of health care. I thank God that he activated your gift to care for others, and please know that you will be greatly missed. Yours Truly Appendix E Photos from HCBT End of Program Event Kids wait to have their face painted. Staff and program participants enjoy dancing together. Adult program participant gives a testimonial Caregiver of child program participant receives a prize after giving a testimonial. SUHI/HCBT and CHA staff. Children playing in the bounce house. Appendix F Presentations conducted by HCBT staff throughout the course of the program Conference/Event University of Illinois at Chicago(UIC) Minority Health in the Midwest Conference 2012 American Public Health Association 140th Annual Meeting Date 2/15/2012 CHA Report Back/Progress Update Meeting 12/13/2012 UIC Minority Health in the Midwest Conference 2013 2/22/2013 Environmental Protection Agency (EPA) Webinar 5/16/2013 2013 Health Center and Public Housing National Symposium 6/4/136/6/13 10/30/2012 Name of Presentation CHW models for the elimination of health disparities: Effectively training and evaluating CHWs to deliver asthma education Translating a communitybased healthy homes asthma intervention to Chicago public housing: Successes and challenges to the CHW model Translating a communitybased healthy homes asthma intervention to Chicago Public Housing: Successes and Challenges Reducing asthma disparities through healthy housing and community empowerment: Evidence from a CHW led intervention Addressing Asthma in Chicago’s Public Housing: A collaborative model integrating a communitybased asthma intervention into a large public housing authority Integrating a communitybased asthma intervention into a large public housing organization: successes and challenges of a collaborative model Presenter Jessica Ramsay, Intervention Coordinator Audience Healthcare professionals from across the Midwest Melissa Gutierrez, Jessica Ramsay Public Health Professionals from across the nation All HCBT Staff CHA, Property Management and Family Works staff from six CHA developments Healthcare professionals from across the Midwest Kim Artis, CHW Melissa Gutierrez (SUHI), Andy Teitelman (CHA) Professionals across the nation Melissa Gutierrez (SUHI), Andy Teitelman (CHA) Professionals across the nation Appendix The Nation's Health Article ts&t lssues at the state and cornrnunity levels Community health workers key to Chicago asthma intervention success health worker Kim Artis heard about a new effort to help Chicago pub- lic housing residents living with asthma, she jumped at the chance to take part. wanted to be part of something that would empower the community, educate them and eventu- ally bring them better health,? Art-is said. have asthma, I have family members who have asthma and you're always wonder- ing what you can do to be better. I've been able to not only empower myself, but to educate those close to me.? Ards was referring to Helping Children Breathe and Tlutive in Chicago Pub- lic Housing, a partnership between Sinai Urban Health Institute and the Chicago Housing Authority that uses community health workers to reduce the effects of and help residents better man- age their health. The pro- gram, which ran from 2011 to 2013 with ?.Lndi.ng from the U.S. Department of Housing and Urban Devel- opment, was offered in six Chicago public housing developments and resulted in a variety of positive health outcomes, from decreased asthma symp- toms to improved housing conditions. Asthma rates among public housing resi- dents are often higher than the general population. The program was not the first asthma interven- tion for Sinai Urban Health Institute, but it was the first time it partnered with the city housing authority, said member Melissa Gutierrez Kapheirn, MS, who directed the asthma inter-_ vention and is an epidemi- oiogist at the the heart of the program was not only a strong partnership with housing officials, but a com.rnit- ment to recruiting commu- nity health workers who lived in housing atlthoriliy communities. Community health Workers received 75 hours of u-aining on all aspects of asthma and were randomly shadowed throughout the program. To find residents living with asthma, they worked closely with the housing authority's case management program and interacted with residents at food pantry events, back- to-school events and health fairs. Eventually, the pro- gram enrolled 73 adults and 35 children. ?Because I'm from the oomrnunity, they were will- ing to listen to me.? said Artis, who worked with about 100 of the partici- pants, many of whom lived in the same public housing development that Artis lives in. ?We always reas- sured people that we weren?t there to judge, it was all about making them feel better.? During the intervention period, community health workers provided in-home asthma education and assessed homes for environmental asthma triggers, such as posts. Workers also con- nected residents to health care providers and resources such as tobacco cessation. Sometirnes, health workers found haz- ardous housing conditions that residents could not mediate on their own, such as moldy carpets. But because of the partner- ships built tvith housing officials and local property managers, many such issues were resolved. Artis noted that another positive outcome of the interven- tion was empowering resi- dents to work within the system to address housing problems. Preliminary health out- comes reported in May were encouraging. Accord- ing to Kapheim, the [re- quency of daytime asthma. among children and adults in the previous two weeks declined from 4.3 to 1.5, night decreased from 3.1 to 1.5, and days that participants needed asthma rescue meditation declined from 5.5 to 1.8. By the_interven- tion?s six-month mark, emergency room visits had declined by nearly 69 percent and urgent health care use decreased by more than 68 percent. In regard to environ- mental triggers, evidence of mice and dampness decreased within six months. Also, of the 25 homes reported to man- agement with housing issues, 15 had issues resolved as of May. ?We've heard nothing but good things about the intervention,? said Andrew Teitel.rna.o. MA, LSW, vice president for resident ser- vices at the Chicago Hous- ing Authority. ?As a housing authority we are very con- cerned about the resident population and about help- ing people to advance, and poor health is a major impediment to To download a webinar presentation about the pro- gram, visit comrnunitynerwork.org/ webinars. Kim Krisberg Photo oourtesy Program, Slnal System Community health worker Kim Artis, right, reaches a commu- nity member about asthma at a World Asthma Day health fair held at :1 Chicago Housing Authority development. 101 THE HEALTH ot- AUGUST 2013