Commonwealth Medicine
333 South Street, Shrewsbury, MA 01545
508.856.6222 l 800.842.9375
www.commed.umassmed.edu
Advancing Asthma Treatment
Beyond the Clinic:
Sai Cherala MD, MPH and the
Worcester Prevention & Wellness
Trust Fund Asthma Taskforce
Worcester Prevention & Wellness Trust Fund Pediatric Asthma Intervention
SITUATION
Why Pediatric Asthma?
■■
■■
Asthma is prevalent among low income
populations living in public and older housing
stock, particularly among Hispanic and Black
populations.
RESULTS
Impact to Date
Pediatric asthma-related emergency room visits
are nearly double in Worcester compared to
the rest of the state.
■■
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
Quitworks –
Smoking Cessation
Services
Follow-up: 52
• 6 Month Follow-up: 12
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
1,000
800
768
600
400
200
0
Worcester
Initial and Ongoing
Environmental Triggers
Insects and Rodents
Mold
Stuffed
Animals
referrals for legal issues
• Cost savings to patients and families for
identified housing issues impacting asthma
such as mold, pests and rodents
Carpeting
8
Strong
Cleaners
Others
■■
■■
Asthma Intervention Workflow
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
Outreach Call or Contact
■■
■■
■■
■■
by clinical care team member
Specially trained & embedded
CHWs conduct home visits to:
■■
Office Visit
with clinical care team
–– Identify and address home triggers
–– Ensure families understand
medications and use
CLA
Clinical Team
Review &
Outreach
–– Conduct follow-up and communicate
with primary care provider and school staff
■■
Enhanced
Communication
conducted by CHW
–– Document findings and
recommendations through Redcap
■■
Home
Assessment
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
Follow-up
Visits
by CHW
■■
with WPS or Head Start nurse
Specialty
Referral
Training Programs
provided
(pulmonology,
allergy)
to WPS/Head Start nurses,
clinical providers, parents,
guardians and students
19
%
9
%
10
%
12
%
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
CONCLUSION
Future – Next Steps
Communication/
Recommendations to
Providers by School Nurses
■■
i.e.: controller medications, referrals
(Pulmonology part of team)
Community Legal Aid (CLA) provides legal assistance for identified
housing issues impacting asthma such as mold, pests and rodents
%
Challenges
Target Population
Children with mild, moderate, persistent, severe asthma
11
%
Tobacco
Smoke
PROGRAM MODEL
■■
10
%
16
Pets
Care Management for High Risk Patients; Home-Based Multi-Trigger,
Multi-Component Intervention; and School-Based Programs
5
%
%
Dust Clutter
• 29
Source: Outpatient Emergency Department Visit Data from the Center for Health Information and
Analysis for 2009-2011, MDPH2
18
%
Other
–– CLA Follow-up:
State
22
%
Follow-up
with PCP
• Data
1,200
34
%
Follow-up with
School Nurse
–– Pulmonology Follow-up:
1536
1
%
2
%
Exercise
• 30-Day
1,600
20
%
Community
Legal Aid
• Baseline:104
1,800
3
%
Integrated Pest
Management
–– Home visits: (Total home visits = 168)
Pediatric Asthma-Related ED Visits
(Ages 2-18 Years-old) 2009-2011
(per
100,000
visits)
Visits
1,400
Referrals Made to Date
Ongoing Follow-up/Education
by pulmonology school team
■■
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
PARTNERS
Worcester Prevention & Wellness Trust Fund Pediatric Asthma Program Model
■■
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
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Community Partners:
–– Worcester Public Schools and Head Start Program
–– Worcester Community Legal Aid
–– City of Worcester Division of Public Health and
Healthy Homes Office
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Respect and collaboration for and
with all team members
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Frequent meetings keep the ball rolling
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Importance of CHWs as care team members
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Addressing asthma in the school setting
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Identify the highest risk asthmatics in
the hospital