Community Health Works

Journal of Asthma, 43:667–673, 2006
Copyright !C 2006 Informa Healthcare
ISSN: 0277-0903 print / 1532-4303 online
DOI: 10.1080/02770900600925288
ORIGINAL ARTICLE
The Yes We Can Urban Asthma Partnership: A Medical/Social Model
for Childhood Asthma Management
SHANNON M. THYNE, M.D.,1,∗ JOSHUA P. RISING, M.D., M.P.H.,1 VICKI LEGION, M.P.H.,2
AND MARY BETH LOVE, PH.D.3
1
Department of Pediatrics, University of California, San Francisco, California, USA 2
Health Education and Community Health Studies Department, City College of San Francisco; Yes We Can Urban Asthma Partnership,
San Francisco, California, USA 3
Department of Health Education, San Francisco State University, San Francisco, California, USA
Pediatric asthma programs have struggled to integrate children’s medical and social needs. We developed and piloted an integrated team model for
asthma care for low-income children through the Yes We Can Urban Asthma Partnership. Program evaluation demonstrated increases in prescribing
controller medications (p < 0.05), use of action plans (p < 0.001), and the use of mattress covers (p < 0.001); and decrease in asthma symptoms
(p < 0.01). Additional changes occurred within the local system of asthma care to support ongoing efforts to improve asthma management. We
conclude that pediatric asthma programs can effectively target the social and medical needs of children in a sustainable manner.
Keywords health disparities, asthma, underserved children, chronic disease management, community health workers
INTRODUCTION
Asthma is the most prevalent chronic disease among children. According to 2002 data, 9 million American children
(12% of all children) have asthma, 4 million of whom have
experienced an attack in the past 12 months (1, 2). Economic
and racial disparitiesin the prevalence and severity of asthma
are well documented, with low-income and minority children
more likely to be diagnosed with the disease (1). Even after
controlling for this higher disease burden, minorities and the
poor aremore likely to receive care in emergency departments
and require hospitalization for asthma (3–8). Further, they are
less likely to receive appropriate therapy to prevent exacerbations (4, 5, 7, 9, 10). This trend is especially marked in the
inner city, where minority and economically disadvantaged
children are exposed to other asthma-associated factors such
as poor housing conditions, environmental tobacco smoke,
crowding, air pollution, and other airborne allergens (11).
Asthma, like other chronic conditions, requires regular
medical assessment and ongoing self-management. Unfortunately, the combination of suboptimal medical care with social and environmental challenges contributes to poorly controlled childhood asthma. This has negative consequences on
children’s schooling and parents’ work attendance. This article provides background on prior attempts to control childhood asthma and introduces the Yes We Can program, addressing some of the medical and social issues we judge to
be important for optimizing childhood asthma management.
We also report on the pilot phase of this program’s implementation and its impact on our community.
∗Corresponding author: Shannon M. Thyne, Department of Pediatrics,
San Francisco General Hospital, 1001 Potrero Avenue, MS6E, San Francisco, CA 94110; E-mail: [email protected]
Summary of Prior Interventions
Interventions for asthma can be classified into three categories: (1) those that rely on a medical model (2), those that
rely on a social model, and (3) those that attempt to incorporate both. Table 1 contrasts the medical and social models of
asthma management. In general, the medical model of care
targets practitioner knowledge and behavior, whereas the social model works to improve the self-management skills and
social and physical environment of the patient and family.
Some interventions have approached asthma care with the
goal of improving the medical model, a natural target given
practitioners’ poor adherence to national guidelines (7, 12–
14). Programsinclude intensivemedical casemanagement by
nurse practitioners(15), and single-session clinician trainings
(16, 17). These programs have shown some success, although
the duration of benefit from these interventions is mixed
(18–20).
Other interventions have targeted the self-management
skills and social environments of children. For many children with asthma, the home, school, and neighborhood are
difficult environments to support adherence to medical recommendations (21) and implementation of environmental
controls. Environmental triggers are known contributors to
asthma morbidity (4, 5, 11, 22, 23). Reducing or removing
triggers, while difficult (24, 25), has achieved positive results
(26–35). Most encouraging is a multi-site recent evaluation
of the impact of community health workers who visited the
homes of children with asthma to address environmental exposures. This intervention resulted in a significant reduction
in asthma symptoms and urgent health care visits among children receiving these services (36).
Interventions combining both medical and social models
promise to have the largest impact for childhood asthma. Not
surprisingly, comprehensive interventions have been difficult
667
668 S. M. THYNE ET AL.
TABLE 1.—Comparison of medical and social models of asthma management.
Component of intervention Medical model Social model
Formulation of principal barrier to
asthma control
Practitioners do not correctly diagnose asthma or prescribe appropriate pharmacotherapy
Social stressors and environmental triggers exacerbate the
underlying disease
Location of intervention Hospital or clinic Home or community
Focus of intervention Appropriate medications Family empowerment and environmental improvements
Care providers Usually medically trained practitioners (physicians or
nurse practitioners)
Usually less-intensively trained practitioners (social
workers, health workers, or nurses)
Level of technology Often high (spirometry, computerized records, etc.) Usually low Behavioral modification efforts Sometimes Often
Disease management programs Sometimes Rarely
Patient education Variable level Variable level
Inclusion of primary care clinician Sometimes Rarely
Reinforcement of the other model Rarely Frequently
to implement and evaluate,with only a fewexamplesin the literature (20, 37–42). Of note, we are unaware of any programs
that work to improve both the quality of direct medical care
and the social supports for children with asthma. The following is a description of our efforts to address both social
and medical components of asthma care for children through
the Yes We Can Urban Asthma Partnership. Additionally, we
present the results of the Yes We Can pilot program, implemented in an urban pediatric clinic.
METHODS
In 1997,Community HealthWorks, a programof San Francisco State University and City College of San Francisco,
convened the Yes We Can Urban Asthma Partnership in collaboration with 17 local medical, governmental, and social
service organizations. The goal of Yes We Can was to address
disparities in pediatric asthma care in San Francisco, a city
with asthma rates and racial disparities similar to those in
other urban areas of the United States (43–45). Yes We Can
is a medical/social care model for clinic-based, communityfocused, team-oriented pediatric asthma management. The
development, demonstration, and evaluation of this project
took place at San Francisco General Hospital (SFGH), and
the program was later expanded to two community clinics.
Developed using the Chronic Care Model (46), Yes We Can
was designed to demonstrate a real-world approach to asthma
care that could yield improved health outcomes and could be
expanded with relatively modest funding.
Yes We Can had four specific goals:
1. to develop a medical/social team model for asthma care of
low-income children;
2. to augment the model’s impact through system and policy
change, such as improved access to medications, health
insurance, and environmental control measures;
3. to develop and disseminate materials to a national audience; and
4. to apply the model to other chronic diseases.
A distinguishing feature of this medical/social model isthe
use of community health workers. Community health workers are community members who have undergone training
in health education and social support, in this case through
an associate level certificate program at City College of San
Francisco (47). They provide culturally sensitive, focused
health education and social support to patients and families
in conjunction with and as a supplement to clinical care. Incorporation of community health workers into the care of
asthmatic children aims not only to add this direct family
support but also (and equally) to improve the medical care
provided by clinicians who get regular feedback about how
the medical regimen is working in the family’s daily life.
San Francisco General Hospital (SFGH)—the universityaffiliated, publicly funded hospital for the city—had an existing pediatric asthma clinic that served as the implementation
site for Yes We Can. Children with unstable asthma were
referred by community providers, public health nurses, and
schools. Additionally, children seen for acute asthma visits
at sites within our health network were recruited into the program through an aggressive outreach campaign by Yes We
Can staff.
Yes We Can at SFGH included three components:
1. medical evaluations (conducted by clinic physicians, and
nurse practitioners): medical assessment, spirometry, allergy skin testing, and provision of an action plan;
2. social interventions (conducted by community health
workers during clinic visits and at separate home visits):
review of the asthma care or “action” plan, discussion of
environmental triggers and appropriate medication use,
and an assessment of other stressors such as housing and
health insurance; and
3. integrated efforts (performed by clinicians and community health workers): patient education,socialsupport, and
community outreach.
Typically, a patient with unstable persistent asthma received three to five asthma clinic visits, interspersed with two
to three home visits. Clinicians and community health workers participated in frequent case conferences, where relevant
medical and social information was reviewed and an asthma
care plan was created. Feedback, including the asthma care
plan, was then given to referring primary care providers after
each patient encounter. An overview of the program can be
found in Figure 1.
At each asthma clinic visit, patient demographics, as well
as medical history and educational interventions, were entered into a database developed by clinic staff. Additionally, community health workers collected information during
home visits to track educational and environmental interventions.
In 2002, records were reviewed to gather pre- and postintervention data related to the pilot program. The following
evaluation includes a convenience sample of patients who
met these selection criteria: (1) two or more asthma clinic
visits within a 12-month period and (2) at least one asthma
THE YES WE CAN URBAN ASTHMA PARTNERSHIP 669
FIGURE 1.—The Yes We Can integrated medical/social model for childhood asthma care.
clinic visit after an initial home visit. When two siblings were
receiving care, only the sibling who first entered the program
was included. Institutional Review Board approval was obtained from the University of California, San Francisco, for
this evaluation.
Outcome measures for this evaluation included prescription of controller medications, creation of asthma action
plans by asthma clinic staff, and change in forced expiratory volume in 1 second (FEV1) over the course of
enrollment. Prescription of a controller medication was
determined to occur if the patient was diagnosed with “persistent asthma” in the database and was prescribed a daily
asthma controller medication (inhaled corticosteroid). Creation of an action plan was determined to occur if the
670 S. M. THYNE ET AL.
patient had an action plan in the database after the first clinic
visit.
In addition, several patient-reported outcomes were monitored: exposures to tobacco and pets, use of mattress and
pillow covers, change in day and nighttime symptoms, and
activity impairment. For environmental questions, an answer
of “yes” to the following questions: “Are there any pets in
your home?” “Are there any smokers in your home?” and
“Do you have mattress and/or pillow covers on your bed?”
was considered a positive response in our database query.
For questions regarding symptoms, we queried a database
drawn from intake interviews, using data points such as the
number of days reported for daytime symptoms, nighttime
symptoms, and activity impairment in the 2 weeks before
the asthma clinic visit. Responses in these patient-reported
areas were compared between the first and last visits.
Pulmonary function testing was attempted using a KoKo
Spirometer (Louisville, CO), using standardized norms for
age and race, at all visits for patients greater than 4 years
of age. For those who were able to comply with testing at
the first and last visits, the database values for FEV1 were
compared from the first to the last visits.
Statistical analysis, using pre- and post-measures, was
done using the Wilcoxon Signed Rank test.
RESULTS
Patient Outcomes
One hundred and two new asthma clinic patients met the
criteria outlined above during the study period (1999-2001).
The parents of 65 ofthese children agreed to at least one home
visit for their child; these children were used as the convenience sample. Information on the reason for refusal was not
collected. Although specific outcome data was not collected
on those patients who refused home visits, the demographics
of the entire eligible population did not differ from that of
the home visit group (see Table 2). Patients averaged four
clinic visits and were received follow-up for an average of
6.6 months, and 60% received the goal of two or more home
TABLE 3.—Outcomes from the Yes We Can medical/social model (average follow-up period 6.6 months).
No. of First clinic After first At last
patients (n) interview clinic visit clinic visit p value
Medical interventions
Patient prescribed controller medication if diagnosis is persistent asthma 65 44% 100% — <0.01
Patient has Asthma Action Plan 65 <1% 100% — <0.001
Social/environmental interventions
Patient reports exposed to tobacco smoke 65 36.5% — 17% =0.5 NS
Patient reports pets in the home 65 11.5% — 5.7% =0.7 NS
Patient reports using bed covers 65 5.7% — 94.3% <0.001
Patient outcomes
Days with asthma symptoms in the past 2 weeks 65 5.1
95% CI
3.5–6.4
— 2.8
95% CI
1.9–3.6
<0.01
Nights with asthma symptoms during the past 2 weeks 65 5.0
95% CI
3.6–5.4
— 2.7
95% CI
1.7–3.7
<0.01
Days with activity impairment in the last 2 weeks 65 4.1
95% CI
2.7–5.4
— 2.5
95% CI
1.5–3.4
<0.01
FEV1 (% predicted for age and ethnicity) for children >4 years of age 42 82
95% CI
79–94
— 91
95% CI
84–95
=0.27 NS
TABLE 2.— Baseline patient demographics for home visit and asthma clinic
evaluations.
Yes We Can patients Asthma clinic total patient
(n = 65) population (n = 102)
n Percent Percent
Ethnicity (self-reported)
Latino 28 43 43
African American 28 43 40
Asian American 7 11 11
White/other 2 3 7
Gender
Male 43 66 57
Female 22 33 43
Age Mean 7.3 years – Mean 6.2 years
0–4 24 37 47
5–11 33 51 42
12+ 8 12 11
Asthma severity
Intermittent 11 17 19
Persistent 54 83 81
visits. Of note, 10 patients who had agreed to home visits
never received them despite outreach efforts. Data analysis
was conducted on all patients who initially agreed to home
visits based on the intention to treat.
Table 3 summarizes observations from the Yes We Can
demonstration project. Following the first clinic visit, prescription of controller medications and creation of an asthma
action plan (p < 0.001) were significantly increased (p <
0.01 and p < 0.001, respectively). Additionally, patients reported a significant increase in the use of mattress and pillow
covers in the home (p < 0.001). Exposure to smoke and pets
in the home did not significantly change but trended toward
improvement.
Days with asthma symptoms decreased significantly (5.1
to 2.8), as did the number of nights with symptoms (5.0
to 2.7). Activity impairment showed a similar improvement
(p < 0.01 for all measures). Among children over 4 years
of age who were able to complete spirometry, FEV1 values
did not change significantly, although they trended toward
improvement.
THE YES WE CAN URBAN ASTHMA PARTNERSHIP 671
Measuring Success in Terms of the Yes We Can Goals
The success of Yes WeCan should also be measured against
the four goals initially established by the Partnership.
1. To develop a medical/social team model for preventionoriented asthma care for low-income children. Yes We Can
created a medical/social model thatsuccessfully targeted and
improved two areas ofsystemic weaknessin pediatric asthma
care: the lack of appropriate medical therapy for children with
asthma and the multiple environmental and social factorsthat
complicate asthma self-management. We defined success in
the area of appropriate medical therapy as changes in six areas: (1) controller medication, (2) use of an action plan, (3)
decrease in daytime asthma symptoms, (4) decrease in nighttime asthma symptoms (5), decrease in activity impairment,
and (6) improvement in FEV1. We defined successin the area
of social interventions as changes in three areas: (1) report of
decreased exposure to tobacco smoke in the home, (2) report
of decreased exposure to pets in the home, and (3) report of
increased use of mattress and pillow covers. For five of the six
medical measures and one of the three social/environmental
goals, there was significant change.
While this multidisciplinary model’s evaluation hasshown
improvement in several outcomes, the clinicwas developed as
a site of medical/social care rather than as an extension of an
academic research laboratory. At present, we are undertaking
more rigorous evaluation of thisintervention, including additional patient and provider outcomes, provider effectiveness
and cost-effectiveness.
2. To augment the model’s impact through system and policy change. The Yes We Can demonstration catalyzed the
development of new systems and local policies. For example, the San Francisco Department of Public Health and the
local Medicaid programs now provide a no-cost source of
asthma supplies, including spacer devices, medication boxes,
educational materials, and mattress/pillow covers.
The San Francisco Department of Public Health and Board
of Supervisors showed support for the project by incorporating the community health worker positions into the
city budget, a noteworthy step during a time of budget
shortfalls. In addition, providers from the asthma clinic offer regular training sessions with clinical staff from the
city’s health centers, school system, and medical training
institutions.
Finally, the original Yes We Can work group at San
Francisco State University and City College launched a
statewide policy initiative aimed at improving Medicaid
reimbursement for asthma preventive services on a statewide
level.
3. To develop and disseminate materials to a national audience. With the success demonstrated at San Francisco
General Hospital and expansion to two replication sites, the
Partnership outlined the Yes We Can approach in a Toolkit,
published in early 2004 by Community Health Works, Kaiser
Permanente Northern California, and the National Initiative on Children’s Healthcare Quality. The Toolkit contains
manuals for program managers, clinical care managers, and
community health workers, as well as a CD-ROM with
the forms and electronic database developed at SFGH. Information on how to obtain the toolkit may be found at
www.communityhealthworks.org/yeswecan. A second tool
for national replication is an in-depth case study commissioned by the Centers for Disease Control and Prevention
(48).
4. To apply the newly developed medical/social model to
other chronic diseases. This remains a goal for the future
of Yes We Can. As the asthma intervention is scaled up for
replication outside of San Francisco, leadership at San Francisco State and City College is developing a higher education
textbook outlining chronic-care core competencies.
DISCUSSION
In contrast to themajority of prior asthma interventions, Yes
We Can attempts to improve both medical and social aspects
of asthma care. Findings from this preliminary evaluation
leave us optimistic that Yes We Can contributes to improved
care for children with asthma, although we are mindful of the
limitations of the pre/post design. Decreasesin asthma symptoms along with improved adherence to National Heart Lung
and Blood Institute guidelinesfor medication and action plan
use suggest that this program can improve clinical outcomes.
In addition, social and environmental outcomes suggest that
the medical/social model may improve the non-medical components of asthma care. Notsurprisingly,significant improvements occurred in areas where the program added something
to asthma care (medication prescriptions, action plans, bedcovers), in contrast to the more difficult effort of asking patients to change behaviors or take away something (cigarette
smoke and pets). We intend to focus on maximizing Yes We
Can’s additive components as we expand the program.
Overall, the largest additive component of the Yes We Can
wasthe community health workers. In the office, the community health workers promote family self-management through
cultural and linguistic competence and through their intense
education efforts. They then create a bridge to the home environment, reinforcing optimal asthma care here as well. In
both settings, community health workers assume many of the
routine aspects of chronic disease management, making more
efficient use of health professionals. Their efforts reduce the
need for phone calls to the medical providers for refills, clarify issues of medication use, help families navigate the insurance plans and formularies, and provide a personal contact
for other troubleshooting, all of which may be responsible
for a large amount of the program’s success.
Despite the value of this intervention, we did note reluctance among some families to accept home visits as a component of asthma care. When first approached, only 64%
originally agreed to home visits; and even among those who
agreed to the visits, 15% never completed any visits. We were
able review data on those families who had consented to the
study and did not complete visits; however, we did not note
any particular trends. Anecdotally, issues such as immigration status and stability of housing were factorsthat may have
led to home visit refusal.
The lower than expected acceptance of the Yes We Can intervention has led us to review our recruiting strategies and
seek other opportunities to supplement medical care with
the social supports of the community health workers. Since
completion of the pilot, we now offer families a more detailed
672 S. M. THYNE ET AL.
explanation of the components of the home visit and we ensure that the community health worker who will be completing the visit personally deliversthisinformation.We have also
initiated a randomized controlled trial of this intervention to
learn more about the role of community health workers.
At present, we continue to offer home visits. However, we
work with families to meet their individual needs. After determining that a child might benefit from augmented asthma
management extending beyond the clinic visits—owing to
severity of asthma, social barriers to care, or other factors,
community health workers help families to determine how to
best assist them.If a home visit is not acceptable to the family,
the community health worker then offers case management
and support through extensive telephone contacts. Additionally, community health workers have become integrated into
our urgent care visits for asthma, providing immediate teaching and referral to Yes We Can in hopes that the family might
be particularly receptive to services after experiencing the
stress of an acute visit for asthma.
The overall intention with Yes We Can was to assemble a
set of best practices and implement them under real-world
conditions. This effort is analogous to a phase III drug trial,
where best practices are put into place for the population
at large. Our intervention used existing infrastructure and
required a modest budget, and, following the pilot, Yes We
Can was permanently funded at our institution. Several other
clinical sites in our community have implemented the Yes We
Can model, and the Toolkit now provides the template for
further replication.
Our own experiences and interactions with colleagues underscored the importance of integrating medical and social
interventionsfor childhood asthma.Community health workers operating outside of a primary medical team do not have
the social power or organizational traction to improve the
practice of medical clinicians. Conversely, even the most effective medical care is too often undermined by complex
social factors or cultural barriers that are difficult for the
traditional care providers to address. Regardless of the effectiveness of medical interventions or social supports alone,
the added value of coordinated efforts is clear.
The Yes We Can model provides a valuable example of
how to assemble a comprehensive model of asthma care
for inner-city children. Linking the medical services to socialsupports with community health workers participating in
both components has potential to build a stronger patient and
community support for the integrated medical/social model.
Broad dissemination of sustainable community-based preventive health care that addresses both the medical care and
the social components of chronic disease is imperative if we
are to address today’s health care challenges.
ACKNOWLEDGMENTS
The authors would like to thank Andrea Marmor, H.
William Taeusch, Alicia Fernandez, Michael Cabana, and
Elena Fuentes-Afflick for the comments on drafts of this
manuscript and members of the Yes We Can Urban Asthma
Partnership and the San Francisco Asthma Task Force for the
enthusiasm with which they have carried out this endeavor.
The UCSF Department of Epidemiology and Biostatistics
provided valuable support in the statistical analyses for this
paper.
The authors would also like to thank the sponsors of the
Yes We Can Urban Asthma Partnership. While this research
project itself was not funded, Partnership development and
much of the clinical work at San Francisco General Hospital were funded by a grant from The California Endowment.
Replication at community sites was supported by First Five,
through the California Children and Families Commission,
which allocated tobacco tax monies to the California Asthma
Initiative. Finally, support for the production of the materials for national dissemination came from The California
Endowment, Kaiser Permanente, The National Initiative for
Children’s Healthcare Quality and the Fund for the Improvement of Post Secondary Education of the United States Department of Education.
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