Impact to Date ■ Asthma Policy Task Force launched in Year 1 to address environmental issues in schools; pilot to begin at three public schools with high rates of absenteeism and high rates of pediatric asthma

– Home visits: (Total home visits = 168)• Baseline:104 • 30-Day Follow-up: 52• 6 Month Follow-up: 12

– Pulmonology Follow-up: • Data for 64 high-risk Pedi-Pulmonology

patients receiving meds in school showed that in 2013-2014, in total, they had 93 ER visits and in 2014-2015, the visits were reduced to 37

• Out of 64 children, absenteeism data on 9 children, in total, went down from 127 in 2013-2014 to 78 in 2014-2015

– CLA Follow-up: • 29 referrals for legal issues• Cost savings to patients and families for

identified housing issues impacting asthma such as mold, pests and rodents

Challenges ■ Data tracking/acquisition through multiple EMRs

■ Busy providers with increasing demands (EMR not working for them)

■ Turnover of staff/CHWs

■ Difficulty aligning timing of needed trainings with staff turnover and needs

■ Supplies needing to be funded through other sources outside of PWTF – may be a problem in terms of sustainability

■ Inability to service people living outside of the PWTF geographical target area

RESULTS

Advancing Asthma Treatment Beyond the Clinic:

Worcester Prevention & Wellness Trust Fund Pediatric Asthma Intervention

Commonwealth Medicine333 South Street, Shrewsbury, MA 01545508.856.6222 l 800.842.9375www.commed.umassmed.edu

Sai Cherala MD, MPH and the Worcester Prevention & Wellness

Trust Fund Asthma Taskforce

SITUATION Why Pediatric Asthma?

■ Asthma is prevalent among low income populations living in public and older housing stock, particularly among Hispanic and Black populations.

■ Pediatric asthma-related emergency room visits are nearly double in Worcester compared to the rest of the state.

CONCLUSIONFuture – Next Steps

■ Reach highest risk asthmatics in the hospital

– Improved communication between ED and primary care sites

– Services offered to hospitalized patients

■ Build upon the Healthy Schools project

Final Reflections ■ Respect and collaboration for and with all team members

■ Frequent meetings keep the ball rolling

■ Importance of CHWs as care team members

■ Addressing asthma in the school setting

■ Identify the highest risk asthmatics in the hospital

Pediatric Asthma-Related ED Visits (Ages 2-18 Years-old) 2009-2011

(per 100,000 visits)

Source: Outpatient Emergency Department Visit Data from the Center for Health Information and Analysis for 2009-2011, MDPH2

Worcester State

1,800

1,600

1,400

1,200

1,000

800

600

400

200

0

Visits

1536

768

Initial and Ongoing Environmental Triggers

Insects and Rodents

Mold

Dust Clutter

Stuffed Animals

Carpeting

Tobacco Smoke

Strong Cleaners

Pets

Others

5%10%

11%

19%

12%10%

9%

16%

8%

Referrals Made to DateIntegrated Pest Management

Quitworks – Smoking Cessation Services

Community Legal Aid

Exercise

Follow-up with School Nurse

Follow-up with PCP

Other

1%

3%

2%

20%

22%

18%

34%

PARTNERSWorcester Prevention & Wellness Trust Fund Pediatric Asthma Program Model

■ Evidence-based intervention targets students/patients identified as high-risk at clinical sites, schools and Head Start

■ Program links clinical and community partners through Community Health Workers (CHWs) and school nurses

■ Specially trained & embedded CHWs conduct home visits to:

– Identify and address home triggers

– Ensure families understand medications and use

– Document findings and recommendations through Redcap

– Conduct follow-up and communicate with primary care provider and school staff

■ UMass Memorial Pediatric Pulmonology works closely with the Worcester Public Schools (WPS) and provides training programs to WPS/Head Start nurses, clinical providers and staff at clinical sites as well as parents/guardians and students

■ Community Legal Aid (CLA) provides legal assistance for identified housing issues impacting asthma such as mold, pests and rodents

PROGRAM MODELCare Management for High Risk Patients; Home-Based Multi-Trigger,

Multi-Component Intervention; and School-Based Programs

Target Population Children with mild, moderate, persistent, severe asthma

Outreach Call or Contact by clinical care team member

Office Visit with clinical care team

CLAHome

Assessment conducted by CHW

Clinical Team Review & Outreach

Specialty Referral

(pulmonology, allergy)

Enhanced Communication

with WPS or Head Start nurse

Ongoing Follow-up/Education by pulmonology school team

Training Programs provided

to WPS/Head Start nurses, clinical providers, parents, guardians and students

Communication/ Recommendations to

Providers by School Nursesi.e.: controller medications, referrals

(Pulmonology part of team)

Follow-up Visitsby CHW

Asthma Intervention Workflow

■ Clinical Partners: – Edward M. Kennedy Community Health Center – The Family Health Center of Worcester – UMass Memorial Pedi-Primary Care, Pediatric Pulmonology,

Plumley Village Health Services and the Office of Clinical Integration

– UMass Memorial Community Relations

■ Community Partners: – Worcester Public Schools and Head Start Program – Worcester Community Legal Aid – City of Worcester Division of Public Health and

Healthy Homes Office