Washblog

The annual direct health care cost of asthma (for all age groups) in Washington is $240 million per year; indirect costs (e.g. lost productivity) add another $166 million, for a total of $406 million dollars. (2)  Childhood asthma costs are estimated at $127.8 million. In King County, 648 children are hospitalized each year for asthma, at a cost of $3.5 million per year ($5451 per admission). Medicaid paid for 42% of these hospitalizations.

Low income and minority children bear a disproportionate share of the burden of asthma. In both the nation and King County, asthma prevalence among black children is 62% higher than among whites. (1) Nationally, the emergency department visit rate among black children is 250% higher. (4)  In the United States, children living in households with incomes less than $20,000 are 30% more likely to have had an asthma attack in the past year than those living in families with incomes over 75,000. (5)  In King County, children living in households with incomes less than $50,000 are 41% more likely to have asthma than those living in more affluent households. (1)  The rate of hospitalization for asthma among children living in low-income King County neighborhoods is 188% higher than the rate among children living in more affluent areas. (1)

Efforts to control asthma may also yield additional health benefits. The costs of childhood diseases and disabilities attributable to environmental contaminants in Washington State is estimated to be $1.9 billion (2004 dollars). (6,7)    Reducing exposure to asthma triggers will also reduce exposure to environmental contaminates such as lead, pesticides, PBDEs, arsenic and others that cause neurobehavioral disorders, childhood cancer, cardiovascular disease and possibly birth defects.  It is estimated that a reduction in childhood asthma would result in a similar decrease in other childhood diseases. Thus, an investment that produced in a 20% reduction in asthma would yield a savings of approximately $360 million annually (2004 dollars).

We estimate that that 6000 children age 0-17 living in King County households with incomes less than 200% of the federal poverty limit have asthma. Asthma interventions are most cost effective when they focus on children with more severe disease. One way to measure severity is by assessing frequency of symptoms. Approximately 29% of children with asthma have moderate to severe symptoms, meaning they have symptoms and activity limitation every day. This suggests that 1700 low children with asthma in King County have moderate to severe symptoms. Our proposal focuses on improving control of asthma among these children.

Home visits
Helping children with asthma and their families develop the skills to self-manage asthma is a core element of the asthma guidelines promulgated by the National Institutes of Health  (8) and many professional organizations. (9)  Home visitation has become an increasingly popular strategy for providing self-management education and support, especially as the difficulties in obtaining consistent attendance at classes or well-asthma clinic visits have become apparent. Clients of a home-visit program are more likely complete self-management education than those enrolling in classes. (21)

Visitors help clients learn self-management skills such as using medication properly, knowing what to do when asthma symptoms worsen, accessing and participating in medical care, and communicating with health providers. They show clients how to identify asthma triggers in their homes, teach them what they can do to eliminate them, and provide trigger reduction resources such as allergen-impermeable bedding encasements, vacuums, furnace intake filters, and cleaning kits

Home visitors directly observe home conditions, such as presence of triggers or availability of asthma medications. Visitors evaluate clients' self-management skills such as inhaler use or vacuuming technique. They develop an individualized approach to self-management and trigger reduction tailored to their clients' concerns, specific allergies and exposure to asthma triggers. They tailor the amount of time they spend with clients. They coordinate care with medical providers by providing them with visit reports that often contain valuable information on asthma status, home conditions or medication adherence. They assess family and psychosocial issues and support clients in resolving them through providing social support and advocacy (e.g. with housing issues, food assistance, insurance coverage, employment).  Working in the context of the home allows visitors to build trusting relationships with clients. These relationships enhance the visitor's effectiveness in motivating behavior change. Detailed descriptions of home visit programs are available at the Seattle-King County Healthy Homes website and in health journals.  (10, 11, 12)

Programs have employed multiple types of home visitors, including community health workers (CHWs), health educators, and nurses.  CHWs are particularly well suited to serve as home visitors among low-income, ethnically diverse households. (12 - 18),  They are effective in promoting behavior change because they share community, culture, and life experiences with their clients, and are readily welcomed into the home. CHWs effectively establish rapport with clients and are less costly than other types of health professionals. CHW asthma programs are becoming widespread. For example, over 600 CHWs have been trained in New York City alone, (12) and the Harlem Children's Zone Asthma Initiative is using CHWs to make home visits.  (9)  Many local health departments and community organizations have developed pediatric home visit programs. (20)  A common challenge facing these programs is lack of stable funding. (21)

CHW programs provide rigorous training and ongoing education and supervision to assure that the CHWs deliver consistent, high quality services. For example, the Seattle-King County program requires 40 hours of didactic sessions, in-class exercises, observation of asthma care in asthma clinics, and field practice before CHWs are deemed qualified to work with clients.  The project nurse monitors CHW performance through observation of three initial visits and at least one home visit per month, review of home visit notes and client action plans and

In addition to their home visitation role, CHWs have provided additional services. In clinics, they provide patient education, assistance with appointment scheduling, patient tracking, and interpretation. (11) In the community, they have organized asthma education events, conducted outreach and assisted support groups.

Effectiveness of Home Visits for Asthma
An emerging body of high quality evidence demonstrates that home visits decrease symptoms, improve quality of life and reduce urgent health service utilization. (22-28)  For example, home visit programs reduce the number of days per year that children have symptoms by 20-40 days (3-7 weeks). This evidence has led to the Department of Housing and Urban Development (29) and the Environmental Protection Agency (30) to recommend home visits.

Costs and Cost-Effectiveness of Home Visits for Asthma
Costs per client vary across programs, ranging from $200-1500. The difference in costs per client is driven by variation in the intensity of the intervention, including number of visits and supplies provided to participants (e.g. vacuums, bedding encasements, air filters). More intensive programs produce larger health benefits (e.g. symptom-free days, quality of life) and reductions in urgent health utilization.

The largest study of home visits (the Inner City Asthma Study) demonstrated a 13.6% reduction in urgent clinic and emergency department use and 11% reduction in hospitalizations, translating into an average of $306 in reduced costs per child over a two year period. (23)

The Seattle-King County Healthy Homes study showed an average reduction in urgent medical care costs during the year in which services were received (combination of unscheduled clinic visits, emergency department visits and hospitalizations) of $2370 per client (in 2005 $US) in the group that received a mean of 7 visits and $2238 in the group that received a single visit. The multi-visit program cost $1538 per client and the single visit program cost $245 per client. While both levels of service appear to yield cost savings, the net savings were greater with the low intensity program. However, health care cost savings alone do not capture the full benefits of the programs. The multi-visit program reduced symptoms by 23 more days per year than the single visit program. It also produced greater improvements in the quality of life of the child's caregiver (e.g. less interruption of work, family schedule, sleep, etc.). If the benefits in reduced utilization were to persist for three years following the service, the higher intensity program would yield greater cost savings than the low intensity program. Follow up data from the Inner City Asthma Study and the King County study show that reduced utilization continues for at least 6-12 months after program participation. Note that the annual cost for a year supply of the asthma medicine fluticasone is approximately $1800 per year.

A recent study sponsored by the American Lung Association concluded that "if targeted at a high-cost high-risk population...[a home visit] intervention is likely to be cost reducing; for a broader population, such an intervention is likely to have a cost effectiveness ratio on par with standard pharmaceutical interventions. (31)

Proposed pilot program
To address the public health problem of childhood asthma, we propose that Medicaid (MAA) conduct a pilot project of home visits by CHWs over a four-year period. Six months would be reserved for program start-up, three years for implementation, and six months for analysis of evaluation data.

Target population
Children age 0-17 with moderate to severe asthma from households with incomes below 200% of the federal poverty level living in King County (number = 1700).

Community Health Workers
Each community health worker can carry an active case load of 60 clients at any point in time and serve 120 clients over the course of a year. Three CHWs can serve 360 clients per year. We estimate that CHWs could reach and enroll 60% of the eligible population, or 1020 children. Over three years, all eligible children would be contacted and served.

Community health workers would be recruited from low-income communities and be bi-lingual, with one each speaking Spanish, Vietnamese and XXX. They would receive a standardized training similar to that provided by Seattle-King County Healthy Homes, as described above.

Several options for siting and supervising CHWs are possible. They could be located at a single agency, with the advantages of centralized and standardized recruitment and referral, quality control and supervision, data collection. Co-location also would provide CHWs with a supportive and collegial environment that would promote cross-learning and flexibility in cross-covering clients. CHWs could also be sited at multiple agencies, especially safety net clinics. The advantage to this would be better integration of CHWs into daily clinic operations, easier communication with agency staff, and easier recruitment of agency clients.

The number of visits would be tailored to family needs. We know that a single visit is likely to provide benefit, although not as much as multiple visits. Each family would receive at least one visit and two follow up telephone calls. Each family and CHW would discuss the benefits of additional visits.

Infrastructure
In addition to CHWs, the pilot would require the following infrastructure:

1. CHW supervision by nurse
2. Clerical support for filing, record keeping, scheduling and recruitment


3. Car leasing for CHW travel to homes
4. Office space, supplies, telephone, computer, copying, etc.
5. Client supplies (educational materials; allergen reduction tools including bedding encasements, vacuums, door mats, HEPA air filters and cleaning kits)

Payment for CHW services
Different payment mechanisms are possible. We recommend that MAA contract with a local agency/agencies to provide services in accord with defined productivity standards. Alternative options include (1) payment on a fee-for-service basis by Medicaid capitated health plans and by Medicaid directly for fee-for-service recipients or (2) a MAA contract with health plans to provide CHW services on a capitated basis.  The latter two options are more complex administratively and therefore likely to be more costly.

Evaluation
Evaluation of the pilot should include the following elements

1. Assessment of demand for CHW services from providers, health plans and patients
2. Assessment of costs and savings using program and MAA and health plan administrative data on health service utilization before, during and after participation in the program.
3. Assessment of health benefits of participating in program.
4. Assessment of effectiveness and efficiency of various client recruitment mechanisms.
5. Review of advantages and disadvantages of location of CHWs.
6. Recommendations regarding standards for scope of work, productivity, training and qualifications of CHWs

1. Song L, Krieger J. Public Health Data Watch: Asthma in King County. Seattle, WA: Public Health - Seattle & King County, 2005.
2. Dilley JA, Pizacani BA, Macdonald SC, Bardin J. The Burden of Asthma in Washington State. WA State Department of Health. Olympia, WA. June 2005. DOH Pub No. 345-201.
3. American Academy of Allergy, Asthma and Immunology, Allergy and Advocate: Fall 2004. Available at: www.aaaai.org/patients/advocate/2004/fall/costs.stm.
4. Akinibami L. The state of childhood asthma, United States, 1980-2005. Advance data from vital and health statistics: no 381, Hyattsville, MD: National Center for Health Statistics, 2006.
5. Bloom B, Dey AN. Summary Health Statistics for U.S. Children: National Health Interview Survey, 2004. Table 1, page 8. National Center for Health Statistics. Vital Health Stat 10(227). 2006.
6. Davies, K. "Economic Costs of Childhood Diseases and Disabilities Attributable to Environmental Contaminants in Washington State, USA" EcoHealth,  June 2006 issue (Volume 3 Issue 2, p. 86-94).
7. Davies, K. with the Research and Information Working Group released "Economic Costs of Diseases and Disabilities Attributable to Environmental Contaminants in Washington State" available at as pdf at washington.chenw.org/pdfs/EnvironmentalCosts.pdf.
8.  National Asthma Education and Prevention Program. National Asthma Education and Prevention Program Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma. nhlbi.nih.gov/guidelines/asthma/asthgdln.htm. Accessed 1/16/07.
9. American Academy of Asthma, Allergy and Immunolgy.  Pediatric Asthma: Promoting Best Practices.  aaaai.org/members/resources/initiatives/pediatricasthma.stm. Accessed 1/16/07.
10. Public Health - Seattle & King County. Seattle Healthy Homes Project. metrokc.gov/health/asthma/healthyhomes/overview.htm. Accessed 10/8/06.
11. Yes We Can. communityhealthworks.org/yeswecan/index.html, accessed 10/8/06.
12. Perez M, Findley SE, Mejia M, Martinez J.  The impact of community health worker training and programs in NYC. J Health Care Poor Underserved. 2006 Feb;17(1 Suppl):26-43.
13. Swider SM. Outcome effectiveness of community health workers: an integrative literature review. Public Health Nurs. 2002;19:11-20.
14. Butz AM, Malveaux FJ, Eggleston P, et al. Use of community health workers with inner-city children who have asthma. Clin Pediatr (Phila). 1994; 33:135-141.
15. Love MB, Gardner K, Legion V. Community health workers: who they are and what they do. Health Educ Behav. 1997; 24:510-522.
16. Krieger JK, Takaro TK, Allen C, et al. The Seattle-King County Healthy Homes Project: implementation of a comprehensive approach to improving indoor environmental quality for low-income children with asthma. Environ Health Perspect. 2002;110(suppl 2): 311-322.
17. Friedman AR, Butterfoss FD, Krieger JW, Peterson JW, Dwyer M, Wicklund K, Rosenthal MP, and Smith, L. Allies Community Health Workers: Bridging the Gap. Health Promot Pract. 2006; 7: 96S-107S.
18. Lewin SA, Dick J, Pond P, Zwarenstein M, Aja G, van Wyk B, Bosch-Capblanch X, Patrick M.  Lay health workers in primary and community health care. Cochrane Database Syst Rev. 2005 Jan 25;(1): CD004015.
19. Nicholas SW, Hutchinson VE, Ortiz B, Klihr-Beall S, et al. Reducing childhood asthma through community-based service delivery - New York City, 2001-2004. MMWR. 2005; 54:11-14.
20. Hoppin P, Jacobs M, Ribble M. Enhancing asthma management using in-home environmental interventions: A review of public health department programs. Dorchester, MA: Asthma Regional Council of New England, September 2006. asthmaregionalcouncil.org. accessed 10/12/06.
21. Brown JV, Demi AS, Celano MP, Bakeman R, Kobrynski L, Wilson SR.  A home visiting asthma education program: challenges to program implementation. Health Educ Behav. 2005 Feb;32(1):42-56.
22. Krieger JW, Takaro TK, Song L, Weaver M. The Seattle-King County Healthy Homes Project: a randomized, controlled trial of a community health worker intervention to decrease exposure to indoor asthma triggers. Am J Public Health. 2005 Apr;95(4):652-9.
23. Morgan WJ, Crain EF, Gruchalla RS, O'Connor GT, Kattan M, Evans R 3rd, Stout J, Malindzak G, Smartt E, Plaut M, Walter M, Vaughn B, Mitchell H; Inner-City Asthma Study Group. Results of a home-based environmental intervention among urban children with asthma. N Engl J Med. 2004;351(11):1068-80.
24. Brown JV, Demi AS, Wilson SR. Home-based asthma education of young low-income children and their families. J Pediatric Psychol. 2002;27:667-688.
25. Dolinar RM, Kumar V, Countu-Wakulcyzk G, Rowe BH. Pilot study of a home-based asthma health education program. Patient Educ Couns. 2000;40:93-102.
26. Eggleston PA, Butz A, Rand C, Curtin-Brosnan J, Kanchanaraksa S, Swartz L,Breysse P, Buckley T, Diette G, Merriman B, Krishnan JA. Home environmental intervention in inner-city asthma: a randomized controlled clinical trial. Ann Allergy Asthma Immunol. 2005 Dec;95(6):518-24.
27. Bonner S, Zimmerman BJ, Evans D, Irigoyen M, Resnick D, Mellins RB.  An individualized intervention to improve asthma management among urban Latino and African-American families. J Asthma. 2002 Apr;39(2):167-79.
28. Carter MC, Perzanowski MS, Raymond A, et al. Home intervention in the treatment of asthma among inner-city children. J Allergy Clin Immunol. 2001;108:732-737.
29. U.S. Department of Housing and Urban Development, Office of Healthy Homes and Lead Hazard Control. Available at: hud.gov/offices/lead/index.cfm.  Accessed May 9, 2006.
30. U.S. Environmental Protection Agency, Air - Indoor Air Quality (IAQ). Available at: http://www.epa.gov/iaq/index.html  Accessed May 9, 2006.
31. Atherly, A. Cost Savings Associated with Home Interventions for Asthma. Washington State American Lung Association.  April, 2006.