Inner City Asthma

Implemented in El Rio Santa Cruz Community Health Center, Tucson, Arizona by MAS Consultants Inc., P.O. Box 5130 Aiken, South Carolina 29804.

This case study was prepared for CDC by Dr. LaMar Palmer of MAS Consultants. The purpose of the case study is to share the experience of one community as they attempt to address the problem of asthma. It does not represent an endorsement of this approach by CDC.

Inner City Asthma: Strengths/Challenges

The program replicates the NCICAS project, a scientifically proven asthma intervention program, the largest asthma study of children ever completed in the inner city. The ICAI sites are provided resources to implement the intervention through the Alliance of Community Health Plans (ACHP), the project administrator for this CDC-sponsored project. ACHP outlined work scope and responsibilities; defined specific core activities; and described referrals, environmental interventions, school-related issues and medication adherence issues the AC is expected to address. ACHP also requires program evaluation, record keeping, and reporting. Eligibility for funding each year to sustain the program depends on successful accomplishment of the project requirements.

Strengths

Tailored intervention
The asthma counselor’s training, education, and experience in social work, combined with the open-ended intervention approach, encourage the AC to tailor the intervention to the needs of each of the children enrolled in the program. The AC is uniquely positioned to help families address a wide variety of problems related to the physical and emotional aspects of asthma. In Tucson, where the client population is from various cultural backgrounds, great flexibility is needed to help effectively overcome barriers to asthma health care. The AC is uniquely positioned to devote adequate time to help families assess barriers to care and to obtain resources. Most families completing the program indicate they liked best two facts about the program: the program staff spent time discussing problems, and the staff cared so much about their children’s health.

Bilingual capability
The addition to the program of a Mexico-born bilingual RT greatly enhanced the program’s effectiveness and viability in Tucson. About 20% first-generation Mexico-born immigrant parents coming to the clinic and enrolling their children in the asthma program do not speak English. Fluent communication with the Spanish-speaking families about their children’s asthma and its treatment is essential. Also, parents and children can be educated simultaneously with two instructors, reducing time, travel, and disruptions to routines for families in the program.

Support from the administrators and physicians at El Rio
The clinic director located the ICAI office within the pediatric clinic just steps from the consulting physicians’ offices. This proximity facilitated a program connection to the underserved children that ICAI was designed to serve. Referrals from the clinic’s physicians to the asthma program are routine and easy to accomplish. Clinic management has recognized the value of the program in reducing medical costs. The Chief Financial Officer and the Chief Executive Officer are committed to continuing the program following completion of the ICAI funding. The physicians seeing children with asthma are enthusiastic supporters of the program. One doctor commented, "Our patients are coming in with so much more knowledge and involvement with their child’s asthma. Now it is easier to work with them."

Directors’ commitment
Both co-directors of the El Rio asthma program are highly motivated, committed, and involved in the program far beyond the program requirements. For example, many inner-city families do not have working vacuum cleaners. Dr. Enright acquires and rebuilds used vacuum cleaners in his spare time. In the first year of operation, he had donated over 30 machines to the program that are then provided to families enrolled in the program who have no vacuum cleaner. Furthermore, Dr. Enright has acquired 100 working used nebulizers for distribution to families in the program. Dr. Manthei accompanied the AC and the case study investigator on a home visit to a Pascua Yaqui Indian family. When Dr. Manthei learned from the mother that she was having trouble obtaining renewal of a prescription for her son’s asthma, he sat at the kitchen table and wrote an extensive message to the boy’s physician about new medications, describing how they interact and what doses are typical and then recommended the doctor contact him for further discussion if needed. He left the note with the mother to take with her to the doctor. Through professional and community contacts, Dr. Manthei actively raises funds to cover the purchase of items recommended but not specifically funded by the program (e.g., incentives, food vouchers). Several thousand dollars have been raised in the first year and commitments have been made for future funding for such purposes.

A program blueprint is in place
Program intervention activities and tasks to be carried out over the year by the AC are clearly described in detail in A Guide for Helping Children with Asthma, published by the National Cooperative Inner-City Asthma Study. The publication includes the best practices and lessons learned from implementing the NCICAS project. (The guide also provides the basis for the AC train-the-trainer course.)

Use of literacy-appropriate instructional materials with dozens of illustrations
The YCCA books used in the educational intervention have been tested over time and found to be effective with inner-city families. The parents’ book is written at the sixth grade level. The often-confusing health-care expressions and technical medical terms used by health professionals in the field have been converted to language that is understandable to the intended population. The El Rio AC and RT also have developed colorful handouts in English and Spanish for the families which supplement the information in the YCCA books.

Behavioral reward for children and parents
This program enrolled 101 families in the intervention in the first year. Only 10 were lost to follow-up before completing the core intervention. The program staff believes that offering a behavioral reward to the children contributes to this high number completing the core. Each child is promised a $20 gift certificate to Target for displaying responsible health-care behaviors by being tested for allergies, keeping an asthma diary, taking the asthma classes, and obtaining an asthma action plan from his/her physician. This has worked so well, that, to try to reduce the no-show rate for follow up appointments, the staff plans to try offering the parents a $20 gift certificate to Target for coming to these appointments.

Families feel comfortable coming to the community health center
They receive allergy testing, spirometry, instruction, and follow up visits in the same location. The ability to provide a one-stop approach for pediatric asthma care that dovetails with the child’s primary care visits is considered a plus.

Challenges

The biggest challenge for the AC is in fitting all the office appointments after school during the school year. The AC and RT can usually only schedule their follow-up visits with the children from 3 to 5 p.m. on most weekdays (Monday, Tuesday, Thursday, and Friday) and on Wednesdays, when school ends early, for an extra 2 hours. They encourage the children to miss as little school as possible. With the high volume of referrals, 12 hours a week for appointments is insufficient. The appointment schedule is often booked over 2 weeks in advance. (Children with scheduled physician visits and sick child referrals are seen in the mornings, so mornings during the school year can be busy, too.)

Many families have difficulty making the follow-up visits because of work or lack of transportation. To overcome this problem, the AC and the RT are considering visiting some homes for the follow-up visits which routinely have been held in the AC’s office. They also try to see families at follow up primary care visits as often as possible.

The program staff expected the work could be confined to an 8 a.m. to 5 p.m. routine. However, about 50% of the mothers work, so ICAI staff cannot contact them until the evening hours. The staff has changed their work schedules to accommodate these families. Flexibility in the work schedule is key, but it burdens the ICAI staff and their families.