Communitybased Interventions The Controlling Asthma in American Cities Project

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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)

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CASL
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Controlling Asthma in St. Louis (CASL)
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CASL Implementation Plans2004 - 2008

• 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

www.asthma-stlouis.org
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Controlling Asthma in St Louis- CAP Clinics
Training Programs Private Clinics
Health Centers

• 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
• Childrens Clinic
• Esse Health
• Forest Park Peds
• Lindell Peds
• Nash
• Southtown Peds
• Tillman
• Tots Thru Teens Pediatric

Graduate sites Updated April 2008
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Community Asthma Program Improves Appropriate
Prescribing inModerate to Severe Asthma

• 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

Moonie S J Asthma 2005
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Moonie S J Asthma 2005
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Moonie S J Asthma 2005
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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

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Asthma Friendly PharmaciesImplementation 2004 -
2008

• 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

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Asthma Friendly Pharmacies

• Developed workflow model and tools
• Fax template to notify PCPs 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 Rxs)
• Staff trained
• 150 pharmacists 150 pharmacy technicians
• 400 graduating pharmacy students trained

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Asthma Friendly PharmaciesLessons Learned

• 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

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Asthma 411 Conceptual Framework
External Support Primary Care Physicians
(PCP) Parents/Guardians Community/Other
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
Internal Support Administrative Support ITS
assistance Teacher Support/Curriculum
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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
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Asthma 411 Indicators of Success
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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

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Home OutreachAsthma HELP

• Partnership with Midtown and St. Janes 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. Janes have incomes below 10K
• CASL/Asthma HELP to date has worked with 163
  high-risk families with 384 home-visits.

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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

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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
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What Institutionalization MeasuresThe 15
organizational areas

• 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

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

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Thank You!

• St. Louis Regional Asthma Consortium
• St. Louis University School of Public Health
• Washington University School of Medicine
• St. Louis College of Pharmacy
• St. Louis Childrens Hospital
• Cardinal Glennon Childrens Hospital
• Institute for Family Medicine
• Missouri Primary Care Association
• AFP Pharmacies, Walgreens and Schnucks
  pharmacies

• St. Louis City Public Schools, Jennings,
  Wellston, Normandy, Riverview Gardens
  Archdiocesan School Districts
• CAP clinics Integrated Health Network/Regional
  Health Commission
• Midtown St. Janes Catholic Charities Community
  Centers
• Healthcare USA, Mercy Health Plans
• Missouri Dept of Health/Asthma Coalition