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Integrating a community-based healthy homes and asthma
intervention into a large public housing organization: successes and
challengesJessica Ramsay, MPH, AE-CSinai Urban Health Institute
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Outline• Background
– Sinai Urban Health Institute– Asthma Epidemiology, Housing and Health– Sinai Asthma Program
• Helping Children Breathe and Thrive in Chicago’s Public Housing– Overview– Intervention– Recruitment– Final Outcomes
• Lessons Learned and Challenges• What next?
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Sinai Urban Health Institute
• Part of the Sinai Health System – located on Chicago’s urban Westside
• Founded in 2000– Group of epidemiologists, health
educators, research assistants, and community health workers
• Develops and implements effective approaches that improve the health of urban communities – Main focus is Chicago’s Westside
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Asthma Epidemiology• Asthma is the most common chronic condition of
childhood– Over 10 million children (14.0% of children <18
yrs) in the U.S. have asthma (NHIS 2011)– Rates vary by race/ ethnicity
• Puerto Rican 30.0%• Black, non-Hispanic 20.7% • White, non-Hispanic 12.3%• Mexican/ Mexican-American 12.2%
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Asthma Epidemiology• Inner-city, minority children experience a
disproportionate asthma burden – Prevalence approaches 1 in 4
• Sinai’s Community Health Survey– Experience more severe asthma
• Mortality and morbidity rates higher in inner-city, minority Chicago communities
– More likely to rely primarily on Emergency Department (ED) for asthma care
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Asthma EpidemiologyPublic Housing Residents• Public housing residents more likely to be
poor and members of racial or ethnic minority, both associated with poor health outcomes (Digenis-Bury, 2008)
• Higher rates of asthma documented among federally assisted housing residents (Northridge, 2010)
• Public housing is associated with higher levels of environmental triggers that exacerbate asthma (Northridge, 2010)
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Asthma Control• A person’s home can heavily impact
asthma symptoms• Many children and families are in
need of individualized education on how best to control asthma
• Asthma is a serious lung disease, yet with proper long-term management it can be controlled and children can live normal lives!
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Four successful previous interventions
– Pediatric Asthma Intervention 1 (Michael Reese Health Trust) 2000-2004
– Pediatric Asthma Intervention 2 (IDPH) 2004-2006
– Controlling Pediatric Asthma through Collaboration & Education (IDPH) 2006-2009
– Healthy Home, Healthy Child (CDC) 2008-2011
– Helping Children Breathe and Thrive in Chicago’s Public Housing (HCBT) 2011-2013
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Helping Children Breathe and Thrive in Chicago Public Housing (HCBT)
April 2011– July 2013
A Healthy Homes Partnership
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Overview• SUHI approached the Chicago Housing Authority
(CHA) to partner in addressing asthma in public housing on Chicago’s Westside
• Funded by the Department of Housing and Urban Development (HUD)
• Based on the framework of Sinai’s established CHW home visit asthma program
• Translated healthy homes asthma model in six Chicago public housing developments
• Utilizes a collaborative approach working with the CHA, building managers, FamilyWorks, and incorporating meaningful participation by the community
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Hiring and Training CHWs• CHWs are recruited from the CHA properties
– No previous asthma knowledge required– Passion for working with community members
• 75 hour training conducted by the Sinai Asthma Education Training Institute– Asthma Overview, Home Environmental
Assessment, CHW Core Skills, HIPAA and Data collection
• Shadowed teaching and role play evaluation• Random shadowing and evaluation
throughout intervention
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Intervention• CHWs are at the heart of the intervention
• Provide home-based comprehensive, individualized asthma education
• Focusing on medical management (e.g., recognizing and responding to attacks, medication adherence and techniques)
• Trigger reduction in the home environment
• CHWs link participants with medical and social services
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Participant Recruitment• Extremely challenging
– Partnered with CHA Case Managers – Added four additional CHA sites
• Identified a lot of adults with asthma– Children: 1 year intervention with 5- 6
home visits– Adults: 6 month intervention with 3-4
home visits• Eligibility Criteria
– Have asthma and live in one of six properties
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Recruitment Numbers
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Evaluation• Program evaluation is a significant part of
all interventions • Data Collection
– Baseline, monthly over the phone, and at home visits
– Via self-report • All activities are documented, which allows
for robust process and outcome evaluation
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Program Completion• Adults (6 Month Intervention)
– 73 adults enrolled• 81% (n=55) completed intervention
• Children (1 Year Intervention)– 85 children enrolled
• 71% (n=60) completed intervention• Lost to Study: 24%
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DemographicsChildren/Caregiver (N=85) Adults(N=73)
Race/Ethnicity 95.3% Non-Hispanic Black 91.8% Non-Hispanic Black
Insurance 92.9% Medicaid 65.8% Medicaid27.4% Uninsured
Income 65.9% <$20,000 63.1% <$20,000
Education 33% high school degree or less 33% high school degree or less
Employment 60% Unemployed 68.5% Unemployed
Relationship 73% single/widowed/divorced 84%single/widowed/divorced
Primary Care Physician 99% report yes* 78% report yes*
* Reporting is different than actual behavior
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Baseline: Asthma ControlNu
mbe
r of p
artic
ipan
ts
(n=1
58)
Well C
ontrolle
d
Not Well C
ontrolle
d
Very Poorly
Controlle
d0
40
80
120
31 31
96
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Final Outcomes: Child Asthma Symptoms
02468
101214
4.13.0 3.1
0.8 0.8 0.9
Baseline Follow-up
*
Days
/Nig
hts (
max
=14)
* Statistically significant difference (p<0.05) per Wilcoxon signed-rank non-parametric test. A 0.5 point change is also clinically significant
Children Symptom Frequency in the past 2 weeks at Baseline vs. average during follow-up year (n=59)
*
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Final Outcomes for Children (n=59):
Urgent Health Resource Utilization*
44%
14%
42%
Year Prior to InterventionNo Urgent HRULess Than One Urgent HRUOne or More Urgent HRU
75%
10%
15%
Intervention YearNo Urgent HRULess Than One Urgent HRUOne or More Urgent HRU
* Sum Emergency Department (ED) Visits, Hospitalizations, and Urgent Clinic Visits
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Final Outcomes:Caregiver Quality of Life
Overall Score Activity Limitation Domain
Emotional Function Domain
0
1
2
3
4
5
6
7
5.45.9
5.1
6.16.5
5.9
Baseline 12 Months
*
Pediatric Asthma Caregiver’s Quality of Life (N=42)^
^This tool is collected once per household* Statistically significant difference (p<0.05) per Wilcoxon signed-rank non-parametric test. A 0.5 point change is also clinically significant
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Final Outcomes:Asthma Triggers
Presence of Home Triggers as Observed During the Home Evaluation Assessment at Baseline and the end of the Intervention for Adult and Child Participants (n=107)
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Housing Referrals• Collaboration with FamilyWorks, CHA, and
property management to develop system of reporting participant housing issues– 30 homes referred with 72 different
issues– 86% (62 issues) of housing issues were
resolved– Moldy carpeting removed, large cracks and holes
filled where rodents and pests were entering, mold from water damage abated, pest control, bed bugs
• Results: Participants reported improved asthma symptoms and improved overall quality of life
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Case Story
“I thank you for all of your hard work and the effort you put forth in not only
educating us about Asthma and the importance of using safe cleaning
products, asthma inhalers and allergy triggers, but improving our overall quality
of life at home. It means a lot and I am thankful to have received you as a case
manager. I also appreciate that your manner and the way you communicated
with us and supported us as a family. Thank you again and sincerest regards,”
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Lessons Learned & Challenges• Collaboration
– Merging two established processes (two cultures)
– Finding key players to work with is essential to success
– Remaining sensitive to residents individual needs while being sure to follow established CHA protocols
– Open and thorough, structured communication from the beginning is key on both ends
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Lessons Learned & Challenges• Community Health Workers
– Quickly and effectively establish relationships of trust with the families that they serve
– Support & mentoring of CHWs is vital to success– Effective hiring and training processes are
essential – Hire CHWs for skills only they can bring (cultural
sensitivity, community connections, etc.). May need support in other areas (e.g., paperwork, managing a case load, computers)
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Lessons Learned & Challenges• Participants
– Economic hardship and competing priorities– Multiple caregivers - important to reach all of
them• Compliance
– Smoking cessation– Medication adherence– Management companies have a process to
modifying the home environment
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What next?• Applied for and received additional funding
from HUD to work exclusively with adults• Helping Chicago’s Westside Adults Breathe and
Thrive, Nov 2013 – Oct 2016• Continued partnership with CHA• Able to implement established processes
with CHA from the previous project with much greater ease
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Teamwork makes the dream work!
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Acknowledgements• Chicago Housing Authority Team: Daniel
Cassell, Vorricia Harvey, Andy Teitelman, • Sinai Team: Kim Artis, Jeanette Avila, Jamie
Campbell, Sheena Freeman, Julie Kuhn, Melissa Gutierrez, Rhonda Lay, Helen Margellos-Anast, Pat Perkins, Jessica Ramsay, Gloria Seals, Dennis Vickers, Steve Whitman
• Funders: Department of Housing and Urban Development – Office of Healthy Homes and Lead Hazard Control
• Partners: Chicago Housing Authority, Chicago Asthma Consortium, Health & Disability Advocates, Metropolitan Tenants Organization, Sinai Children’s Hospital, & Sinai Community Institute
• Participants and their families
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Jessica Ramsay, MPH, AE-C
Intervention DirectorSinai Urban Health
InstituteSinai Health System NR7-
142Chicago, IL 60608
phone: 773-257-2745fax: 773-257-5347
[email protected] www.SUHIchicago.org
