In May 2002, RAMP received a grant from the U.S. Environmental Protection Agency aimed at furthering RAMP's community level support and regional collaboration. As part of the grant, RAMP administered three mini-grants to support in-home environmental assessment and remediation efforts. Based on a list of criteria outlined in the grant application, RAMP selected three programs charged with completing at least 40 home visits by May, 2003: Asthma Start, Oakland Kicks Asthma, and the Monument Corridor Asthma Project. As the grant period is coming to a close, the three groups met in March to share innovative ideas, successes, and barriers.
The information shared will help strengthen their programs and may also be useful for other in-home visiting programs. This article briefly describes each program, their successes, and how they have worked to overcome some common barriers.
Asthma StartThe Asthma Start Program is a project of the Alameda County Public Health Department and addresses asthma in children 0-5 years of age. Two Asthma Coordinators provide in-home visits to: educate families about asthma and asthma medication; perform home assessments to identify what might trigger a child's asthma attacks; plan with families to improve a child's asthma; provide free supplies to minimize household triggers; provide advocacy with landlords and providers; and connect families with other agencies working on asthma.
The Asthma Coordinators collect data to monitor a child's asthma and Asthma Start has used this data to demonstrate how case management services can play a positive role in the improvement of asthma symptoms of children with asthma. They performed a before and after comparison of clients's health history and asthma symptoms between the initial visit and the closing visit. Over 90% of clients showed marked reduction of asthma symptoms or maintained low symptom levels.
They also performed in-home asthma trigger assessments at the second visit and final visit and compared the recommendations at the first assessment with the outstanding needs at final visit. They have documented great success with simple behavior changes, such as keeping pets out of the child's bedroom and discontinuing the use of stoves for heating. The families had difficulty in quitting smoking and changing smoking behavior. Many families also faced serious mold problems that could not be remediated by tenants but rather, needed structural improvements addressed by landlords. The other area of difficulty was in reducing clutter; outreach workers found it difficult to balance the goals of the intervention with the need to respect the families. In general, the Asthma Coordinators have found that providing supplies, such as cleaning supplies or even vacuum cleaners, encourages families to make other more difficult changes to reduce asthma triggers.
Families were very pleased with the intervention overall and follow-up phone survey results revealed 100% satisfaction. For more information on Asthma Start, contact Paul Cummings at (510) 577-7082.
Oakland Kicks AsthmaOakland Kicks Asthma is a project of the American Lung Association of the East Bay. It is a CDC-funded asthma intervention aimed at improving continuity of care between home, school, and provider. The project has multiple components, one of which is in-home visits with environmental remediation to families of teens with asthma. The goal of the in-home visiting, or case management, is to reduce urgent care visits and school absences by increasing asthma self-management skills and access to care, and ameliorating the home environment.
They recruit participants through schools and conduct 3-5 visits over a 3-5 month period. Using a database in Microsoft Access, they track student progress, evaluate case management, and track symptoms, medications, and management, with several hundred outcome measures. They developed a case management manual, unique to this project, which will be revised as the program develops.
Although the project is new, there has been some success to date including low no-show rates, a greater number of referrals than expected, and a user-friendly tracking system. Other outcomes are pending evaluation. For future improvements, they will target only high risk students, and will expand to additional schools. They also hope to have an Oakland Unified School District Nurse to coordinate recruitment and referrals. For more information on Oakland Kicks Asthma, contact Adam Davis at (510) 893-5474.
Monument Corridor Asthma ProjectThere are two in-home visiting programs in Contra Costa County, The Monument Corridor Asthma Project and the California Asthma Among the School Aged (CAASA) project. The Monument Corridor Asthma Project is a project of the Contra Costa Public Health Department, funded by RAMP. The CAASA project is also a project within Contra Costa Public Health, funded by the California Endowment. Community Health Outreach Workers provide in-home visits to families of children, (ages 0 through 18 years) with asthma in Contra Costa County .Central Concord, ages 0-18 years. The Outreach Workers have offices in each of two main targeted communities, housed in a local pediatric clinic and ambulatory care center respectively. are located in the target community, housed in a local pediatric clinic. Many of the clients for the in-home visiting program programs are recruited from the Open Airways for Schools classes, conducted in several nearby local schools. Many others are referred by the clinics, the Public Health nursing staff and the Child Health and Disability Prevention program.
The home visits consist of a review and reinforcement of the prescribed medication regime, including use of the peak flow meter and aerochamber spacer. During the second visit they discuss the environmental triggers that affect the child and provide education and assistance in reducing those triggers. They have developed a presentation which includes a book describing common triggers. The book that contains pictures for low-literacy clients and written language in both English and Spanish, as many of the community residents speak only Spanish. They instruct the families in trigger reduction approaches and conduct an environmental assessment, with the family¡¦s permission. They custom make buckets of free tools to meet the needs of each family. They collect pre and post data one year apart. For more information on the Monument Corridor Asthma Project, or the CAASA project, contact Sally McFalone at (925) 313-6242.
Overall Successes:
* Home visits build strong rapport, decrease no-show rate, and increase efficacy of home assessments„X Distributing free supplies is effective for assisting families in reducing asthma triggers
* Parents and families can easily be encouraged to undertake minor behavioral changes with great success.
* Families are open to home assessments once trust has been established with the in-home visitor.
Overcoming Barriers:
* Smoking Cessation: All three programs described difficulty in getting family members to stop smoking. One way they have addressed this barrier is to focus on harm reduction. Rather than asking family members to quit smoking, they recommend smoking outside, and even wearing a smoking poncho so that the smoke on their clothes is not tracked inside. They do make referrals to smoking cessation programs for those who think they may be able to quit.
* Clutter Reduction: Outreach Workers described the difficulty in asking families to reduce clutter, which can increase dust mites. Not only were there concerns about ¡§telling people how to live¡¨, but many of these families are living in very small, overcrowded places. One suggestion for overcoming this barrier is to provide bins for the storage of belongings, which will keep out the dust mites.
* Mold: While Outreach Workers teach families how to clean mold, the problem is often too large to clean and may be caused by a structural problem (leaks, lack of ventilation, etc.) that would require attention by the landlord. When the landlords refuse to fix the problem, Outreach Workers are faced with a major barrier. Some programs have successfully used a letter-writing program, where a physician or public health official signs a letter asking the landlord to make necessary repairs. However, there is always a risk of retaliation by the landlord, and this may be particularly sensitive when the tenants are undocumented. One way to address this barrier is to connect the tenants with free legal services, so that lawyers can advise them on their rights and the benefits and risks of pursuing various legal options.
* No-shows: While home visits have far fewer no shows than appointments at clinics, outreach workers still described the frustration of finding no one at home. Some improvements were found when reminder calls were made the day before the visit.
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