Community-based Interventions - The Controlling Asthma in American Cities Project

1. Community-based Interventions- The Controlling Asthmain American Cities Project • Cooperative agreements with 7 sites • 2 yr planning, 5 yr intervention phase • Total funding: • $6 million/yr ($900,000 / site) for intervention phase • Target groups: • Defined urban populations (300,000-700,00) with a disproportionate burden of asthma • Youth (2-17 yrs)

2. CASL

3. Controlling Asthma in St. Louis (CASL)

5. Healthcare Provider Education (CAP) Improve PCP clinic and support staff delivery of asthma care using CQI model and standardized asthma education (18 clinics, 200+ PCPs, 6 asthma coordinators of which 2 received their AE-C, 6000+ participants) Based upon NAEPP guidelines severity assessment and appropriate treatment Working with Health Disparities Collaboratives in FQHCs through the Integrated Health Network Improves link to pharmacy, schools, ED/hospital, and the community CASL Implementation Plans2004 - 2008 www.asthma-stlouis.org

6. CC Urgent Care/CardioPulm CC Florence Hill (MHD) CC Homer G Phillips (MHD) CC Max Starkloff (GH) CC Lillian Courtney* (GH) Family Care - Carondelet, FP SE John C Murphy Cty Health Myrtle Hilliard Davis - DMLK, Prince Hall North Central Cty South Cty Health BJH IM residents Forest Park FP residents Institute of Family Medicine Private peds: Arnold/Bridgeton/Chesterfield/ Fairview Hts/Florissant /MidRivers/Sunset Hills* Beeks, Gerst, Reynal* Brownridge Children’s Clinic* Esse Health* Forest Park Peds* Lindell Peds* Nash* Southtown Peds* Tillman* Tots Thru Teens Pediatric Controlling Asthma in St Louis- CAP Clinics Training Programs & Private Clinics Health Centers *Graduate sites; Updated April 2008

7. Prospective, observational study One year time frame 723 children and adults with asthma 2 primary care urban clinics CAP trained clinical staff evaluated: pediatricians, nurse practitioners, family practice physicians, internists Community Asthma Program Improves Appropriate Prescribing inModerate to Severe Asthma* *Moonie S J Asthma 2005

8. *Moonie S J Asthma 2005

9. *P < 0.01 *Moonie S J Asthma 2005

10. Community Asthma Program-What We Have Learned • Asthma can be cared for effectively and efficiently in primary care • Caring for asthma in primary care adds extra work up front (“more paperwork”) but becomes feasible after the initial investment - find ways to improve existing system! • A Physician and Staff “Champion” is needed to encourage use of CAP (“peer pressure”) • Support staff in the primary care setting should be trained as well and are often critical to its success • Integration into existing processes increases acceptance - Breakthrough Collaboratives at FQHCs • Health centers are in dire need of process improvement such as CAP but require additional “hurdles” till final implementation

11. Develop AFP Model to: Address Healthy People 2010 goals for asthma Integrate brief asthma interventions into Rx workflow Identify medication problems: e.g. controller non-adherence, SABA overuse Educate patients: e.g. device technique, tobacco, controller vs relief Efficiently communicate interventions to PCP Implement model into variety of community Rx settings Asthma Friendly PharmaciesImplementation 2004 - 2008

12. Developed workflow model and tools Fax template to notify PCP’s of interventions Patient education materials: book marks and stickers Pharmacy staff and student training video Integration into pharmacy curriculum AFP pharmacies: 40+ (in chain, grocery, independent Rx’s) Staff trained: > 150 pharmacists + > 150 pharmacy technicians > 400 graduating pharmacy students trained Asthma Friendly Pharmacies

13. Asthma Friendly Pharmacy Model: Successfully integrated into pharmacy workflow in multiple types of community pharmacies (chain/grocery/independent) Fax is an efficient method to notify PCP of medication concerns Importance of training, follow-up, reinforcement: Training video valuable to reinforce staff and train new-hires On-site visits to help adapt program to site specific workflow All graduating pharmacists trained by integrating into curriculum Asthma Friendly PharmaciesLessons Learned

14. External Support Primary Care Physicians (PCP) Parents/Guardians Community/Other Care Communication SCHOOL NURSE Case identification Asthma Action Plans Absence and office visit tracking Use of standing orders Establish relationship with PCPs CONSULTING PHYSICIAN Provision of standing orders Policy review/revision Consultations Education Evaluation and Education Internal Support Administrative Support ITS assistance Teacher Support/Curriculum Asthma 411 Conceptual Framework External Support Primary Care Physicians (PCP) Parents/Guardians Community/Other CONSULTING PHYSICIAN Provision of standing orders Policy review/revision Consultations Education SCHOOL NURSE Case identification Asthma Action Plans Absence and office visit tracking Use of standing orders Establish relationship with PCPs Internal Support Administrative Support ITS assistance Teacher Support/Curriculum

15. Asthma 411: A School-Based Asthma Program Goals of 411: To reduce absenteeism and missed class time due to asthma morbidity and improve quality of life of children with asthma in the school setting To enhance current school health services by providing additional tools, methods, and strategies in order to help manage asthma To have districts institutionalize Asthma 411 into their health services program, specifically into the nursing process Reach over five years: Five participating districts totaling 123 schools (Riverview Gardens, Jennings, Normandy, Wellston, St. Louis Public Schools) Over 135 school nurses Over 60,000 students Over 5,000 students with asthma Other programs developed: Asthma awareness curriculum, Explore. Define. Measure. An Integrated Curriculum for the Elementary Classroom Breathe Your Best For School Success www.asthma-stlouis.org

17. Asthma 411 Indicators of Success

18. Integrated Asthma Curriculum • Explore. Define. Measure: An Integrated Curriculum for the Elementary Classroom • Objectives of the Curriculum • Increase knowledge about asthma among elementary school students • Provide teachers with an interactive, integrated curriculum that also meets MO Show Me Standards/GLEs • Contains 15 lesson plans covering the core subjects of Science, Communication Arts and Math using asthma as a real-world example throughout • Created for use by teachers in 3rd-6th grade classrooms • Showed an increase in asthma knowledge and had high teacher “acceptance” • Provides a valuable opportunity for all students to gain a basic understanding of asthma and assist school districts with incorporating asthma and health education into core subject areas

19. Home OutreachAsthma HELP • Partnership with Midtown and St. Jane’s Catholic Charities Community Services to provide asthma education, support and environmental services directly into the home • Services provided by asthma-trained social workers or nurses employed by the centers • Most families within the geographic areas served by Midtown and St. Jane’s have incomes below $10K • CASL/Asthma HELP to date has worked with 163 high-risk families with 384 home-visits.

21. Trends and System Changes with Asthma HELP • Emergency department and hospitalizations are trending lower, but influenced by a few children with many visits. • Linkages were developed between practice sites and centers on client specific asthma-related issues. • Partnership and evaluation have increased the ability of centers to apply for additional funding to support and expand services

22. How Institutionalization is Represented • Measured and monitored all CASL programs/interventions with a validated and reliable instrument. • Little is known about monitoring institutionalization and then responding appropriately. Wilson KD, Kurz RS.  Bridging Implementation and Institutionalization Within Organizations: Proposed Employment of Continuous Quality Improvement to Further Dissemination. Journal of Public Health Management & Practice. 14(2):109-116, March/April 2008

23. Production goals and objectives for program/interventions plans and procedures schedules strategies evaluation (continuous) Maintenance permanent staff assigned administrative advocacy for program/interventions other staff involvement Supportive permanent status assigned to program/interventions Space allotted for program/interventions permanent funding source permanent funding for staff Managerial supervision job descriptions for program/interventions regular evaluation reports What Institutionalization Measures:The 15 organizational areas

24. Example of measuring institutionalization and what it can identify: A breakdown between implementation and institutionalization

25. Why is Institutionalization important? • Identify more specifically where programs and interventions are “sticking” and where it is not. • Low institutionalization may mean higher risk for the programs/interventions to go away after the grant-funding or external support/facilitation goes away. • If the programs/interventions demonstrate benefit, then the goal is to institutionalize the programs so that the benefits continue. • As a result of CASL, can now apply knowledge gained to develop and target strategies to address in new and other existing programs and interventions.

27. St. Louis Regional Asthma Consortium St. Louis University School of Public Health Washington University School of Medicine St. Louis College of Pharmacy St. Louis Children’s Hospital Cardinal Glennon Children’s Hospital Institute for Family Medicine Missouri Primary Care Association AFP Pharmacies, Walgreen’s and Schnuck’s pharmacies St. Louis City Public Schools, Jennings, Wellston, Normandy, Riverview Gardens & Archdiocesan School Districts CAP clinics & Integrated Health Network/Regional Health Commission Midtown & St. Jane’s Catholic Charities Community Centers Healthcare USA, Mercy Health Plans Missouri Dept of Health/Asthma Coalition Thank You!