Background
Perform a literature review and create a summary of findings of similar projects to determine best practices for your project.
Discuss what has been done before that may be relevant and applicable to replicate at your community partner site.
With your community partner, determine which stakeholders should be contacted and perform key informant interviews. Develop a database of key informants and contacts (use your project folder accessed on your Data page).
Asthma is the most common chronic disease of childhood affecting approximately 8.3% of children in the United States and 12.3% in Hamilton County, Ohio (Akinbami, Simon, & Rossen, 2016; Weiss, 2015) and disproportionately affects low income and minority children.(Akinbami et al., 2016) Asthma remains a top contributor to inpatient bed days at CCHMC despite quality improvement work incorporating medication management & home delivery, care coordination, home health visits, school-based initiatives, and academic-community partnerships.(Kercsmar, Beck, Sauers-Ford, & et al., 2017; McCarthy & Cohen, 2013)
One contributor to this disparity is children’s exposure to poor housing conditions with asthma triggers. The National Asthma Education and Prevention Program, the Community Preventive Services Task Force and the American Academy of Pediatrics recommend addressing environmental asthma triggers as part of comprehensive asthma management.(Matsui et al., 2016; National Asthma Education and Prevention Program, 2007; Task Force on Community Preventive Services, 2011) Multi-trigger, multicomponent environmental home interventions reduce symptom days by 21 days/year, school days missed by 12.3 per year and asthma-related acute care visits, including ED visits and hospitalizations, by 68% and 84%, respectively.(Crocker et al., 2011; Woods et al., 2012) These interventions bring trained home visitors to provide education and materials to reduce in-home asthma triggers such as dust mites, cockroach, and moisture-related allergens.
However, interventions focusing on education and behavior change alone may not address the underlying housing conditions that create environmental asthma triggers, such as poor internal air quality, lack of ventilation, moisture intrusion and mold. Incorporating home repairs and other structural modifications as part of a comprehensive home-based intervention has been shown to increase the benefits to patients and decrease the need for asthma-related treatment.(Gruber et al., 2016)
Local stakeholders have made progress addressing the home environment in asthma treatment. The Collaborating to Lessen Environmental Asthma Risks (CLEAR) program, for example, refers children admitted for asthma exacerbations to their local health department if they screened positive on an environmental asthma trigger questionnaire. What follows is a one-time Healthy Homes assessment and educational visit by a public health sanitarian. The sanitarian may also cite the home for code violations,(Beck et al., 2013) but does not provide materials to reduce asthma triggers. Approximately 75 children are referred annually for services. Based on a published review of the CLEAR program, only 50% of children referred had home visits carried out.(Beck et al., 2013) This is substantially lower than environmental asthma programs elsewhere.(Krieger, Takaro, Song, Beaudet, & Edwards, 2009; Woods et al., 2012) Families report concerns about implications of health department inspections on maintaining housing. In a formal asthma needs assessment (funded by the Luther and Verizon Foundations), the pulmonary division at CCHMC engaged adolescents with uncontrolled asthma, their caregivers and school nurses. Most participants identified home environmental triggers as a concern, echoing findings from a qualitative study of families of children with asthma in Cincinnati.(Mansour, Lanphear, & DeWitt, 2000)
Clearly more work is needed to address the gap between the need for home asthma trigger reduction and its implementation. Luckily, there are existing, evidence-based programs, such as the Washington State Department of Health 3-Visit Model Toolkit, the Boston Community Asthma Initiative, and the Kansas City Asthma Friendly Home Partnership that can be applied in Cincinnati. These programs are based on providing education, materials for mild to moderate home interventions and follow-up with families in their homes to support the changes that they’ve made. Additionally, there are established methodologies for evaluating a home and determining what structural conditions may be exacerbating known asthmas triggers like mold, moisture intrusion, poor internal air quality and ventilation, which can guide major home interventions.
Despite the evidence base, barriers to implementation exist at the patient/family, physician/health care provider, and third-party payer levels. However, new funding paradigms—such as value-based reimbursement—may make these programs more feasible for chronic asthma management.(Patel, Farmer, George, McStay, & McClellan, 2014) What has been lacking in Cincinnati is a partnership between a health care entity and an in-home environmental intervention service provider. Through the development of a partnership between People Working Cooperatively and Cincinnati Children’s Hospital Environmental Health and Lead Clinic, we hope to eventually develop a robust multi-trigger home environmental intervention program for children with difficult to treat asthma. The goal is to improve the health for children with asthma in a high-risk population by incorporating known evidence-based environmental home interventions into asthma care.