Nassau County Childhood Asthma Intervention

State: NY Type: Model Practice Year: 2006

Nassau County Childhood Asthma Intervention project targets asthmatic children and their caregivers who reside in low socioeconomic status communities of Nassau County, a large metropolitan suburb adjacent to New York City. To date, 27 children and 75 family members have been directly impacted by the program. Through partnerships, an additional 175 persons have been indirectly impacted. The goal of the program is to provide the child's caretakers with the knowledge, skills, motivation and supplies to perform wide-ranging environmental remediation conducive to reducing the symptoms of asthma. Specific objectives include: increasing the performance and quality of remediation behaviors, linking children to needed health and social services through case management and decreasing the number and severity of asthma symptoms.
NCCAI addresses the public health issues of children’s environmental health, access to care and health disparities. With a population of over 1.3 million, Nassau is larger than seven states and is one of the wealthiest counties in the country. However, this statistic obscures the large low income and lower middle income population concentrated in communities that resemble poor urban neighborhoods. The HD used Behavioral Risk Factor Surveillance System, Youth Risk Behavior Survey, census and hospital discharge data to ensure that the initiative would be relevant to local conditions. Two years prior, the County Executive’s Minority Health Task Force recommended increased collaborations and partnerships among local government, healthcare providers, community based organizations and residents to create initiatives that address healthcare disparities. The program’s inclusion criteria that children reside in one of the low SES communities which are predominately African-American and Latino ensure that these limited resources are being utilized to address disparities. While the program as a whole addresses children’s environmental health, the provision of remediation equipment, supplies and education has the greatest clinical impact in this domain. Access to care is addressed by facilitating enrollment in the State’s children’s health insurance program, providing case management services (i.e. scheduling medical appointments, arranging transportation) and by the partnership with the mobile medical clinic.
Agency Community RolesThe HD is responsible for most of the initiative’s activities. Upon receiving a referral from a community site, health educators and sanitarians perform baseline home evaluations and develop individualized intervention and education plans. Staff provide the equipment and training necessary for wide ranging remediation activities the training and conduct six separate hour-long educational modules, provided at two to four week intervals. The modules include: dust mites, environmental tobacco smoke, cockroaches, pets, rodents, and mold. Children whose caregivers use tobacco are referred to cessation programs, and are eligible to receive free nicotine replacement therapy. Staff also provide families with comprehensive case management services, including referrals for health and social service needs. Representatives from stakeholder and partner organizations have a key role in the planning and implementation stages by participating in the project management group. This group was responsible for overseeing the adaptation of Inner City Asthma Study protocols, selecting educational materials and recommending specific outreach activities. Referral sites contribute by identifying families that could potentially benefit from this program. Those who meet clinical and administrative criteria are contacted by the program coordinator. The local asthma coalition is the primary mechanism through which collaboration takes place. Senior HD staff are active members and serve as chairs of several subcommittees, including patient and community education. The program director provides asthma education to health care, community and faith based member organizations. Several of these have helped identify children now enrolled in the program.   ImplementationWeeks 0-1: Assignment of Project Coordinator: To assure timely start-up of program activities, the medical director (project planner) assigned a health educator as project coordinator as soon as the award was announced. Weeks 2-6: Formation of a project management group: This group, with representatives from the local asthma coalition, local public hospital, and others (i.e. tobacco coalition) oversaw the adaptation of Inner City Asthma Study interventions to Nassau County, selected educational materials, and recommended specific outreach activities. Weeks 0-4: Literature Review: The Project Coordinator conducted a review of other successful asthma prevention and control programs. The review included an examination of the Cochrane Library’s listing of interventions related to environmental tobacco smoke and remediation of allergens. The report described the nature, extent, and potential acceptability of each intervention to the target population. The report was provided to the project management group. Weeks 0-4: Communication with Inner City Asthma Study staff: The program coordinator contacted Dr. Wayne Morgan, principal investigator of ICAS. In additional to providing ICAS protocols and educational modules, Dr. Morgan provided guidance regarding the development and implementation of the intervention. Weeks 4-8: Site Development: The HD consulted the membership of the local asthma coalition to identify interested facilities and organizations already serving the program’s target population. After obtaining support from multiple referral sites (local public hospital, a home health agency, school health center and mobile medical clinic), the program coordinator met with key staff to introduce the program, identify barriers, provide training and determine how to best adapt to each site’s culture. Weeks 8 - current: Logistics and Training: The program director distributed program materials to referral sites and provided orientation and training to staff at each host location. Biweekly contact is made with each site to assess implementation, answer questions, assist staff and review referrals.
Goal:To provide the child’s caretakers with the knowledge, skills, motivation and supplies to perform wide-ranging environmental remediation conducive to reducing the symptoms of asthma. Objective: Increase the performance and quality of remediation behaviors: Performance measures: 100% of enrolled families will deploy remediation equipment and supplies; 85% of targeted behaviors will be successfully demonstrated by caregivers.  Data collection: 1) presence of remediation equipment and supplies in the home; ability of caregivers to successfully demonstrate competency with remediation skills and behaviors; 2) program coordinator; 3) direct observation.  Outcomes (intermediate): 100% of enroleld families deployed remediation equipment and supplies; 92% of caregivers demonstrated competency with targeted behaviors. Objective: Link children to needed health and social services: Performance measures: 100% of identified social service and healthcare needs are addressed; 100% of acute referrals successfully acted upon by caregivers.  Data collection: 1) type of acuity of referral, length of time to appointment/delay in accessing needed services; 2) program coordinator; 3) direct communication with families and verification with social service/health care agencies.  Outcomes (intermediate): 100% of identified social service and health care needs were addressed through referrals to appropriate agencies; 100% of acute/emergency referrals were acted upon by caregivers. Objective: Decrease the number and severity of asthma symptoms: Performance measures: 75% of children will experience a decrease in symptoms.  Data collection: 1) emergency room visits, unscheduled doctor's appointments, school absenteeism; 2) program coordinator; 3) direct communication with families and verification with medical record/health care provider(s).  Outcomes (intermediate): Of the children who have completed the program, 61% have been asymptomatic; 22% became symptomatic with bronchitis and each child's symptoms resolved after antibiotic treatment; 6% became symptomatic with the introduction of a pet; and 11% are undergoing evaluation for other pathology.
Locally, NCCAI has been a tangible success. The initiative was the first to receive a second year of funding from the local asthma coalition. Stakeholders and referral sites have demonstrated a high degree of commitment to the initiative since it utilizes an evidenced-based methodology and provides needed case management services. While several education initiatives have existed in the past, most faced difficulty in maintaining ongoing relationships with families. The trust gained by the provision of case management services has been instrumental in obtaining access to homes and high levels of adherence to individualized plans. This in turn has inspired stakeholders to begin to replicate portions of NCCAI into the existing asthma prevention and control infrastructure. The HD also provides presentations at local professional society meetings and offers demonstrations of remediation equipment during public forums. In cooperation with the asthma coalition, the HD is researching additional sources of funding to expand the program. In the next fiscal year, the HD intends to include the purchase of remediation equipment and supplies in its budget request, doubling the program’s capacity. HD chronic disease and environmental health staff will continue to provide the in-kind services described above.