Rabu, 31 Mei 2017

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we're focused today on asthma care providers and home visiting programs. what this session is about is integrating community health worker services into pediatricasthma care. we're very happy to be meeting today at beautifulwilder center. i hope you found us okay. we're looking forward to a wonderful morningof learning and exchange. a couple words about our program. our program is part of a larger initiativecalled success with chws.

it's funded by the saint paul foundation andminnesota community measurement. we'll get a little bit more into success withchws later after the break, but our learning objectives for today are to increase familiarity with the chw roleand its benefits to patients, to families, communities, and the healthcaresystem; to share ways to integrate chws with membersof your asthma team and to effectively address asthma disparities; and to explore questions around chw scopeof practice, education, financing, and supervision.

then a few words about our alliance beforewe get into the program at hand. our alliance is a partnership that has beenaround for about a decade. a few years ago we incorporated as a nonprofitin minnesota. we have a voluntary board, and we build communityand systems capacity for better health through the integrationof community health worker services. we have a unique mission in our state. this program is prompted over concern, concerni know that you share around asthma disparities in saint paul, inthe twin cities, in our state, and the opportunities we have to really add to ourtool kit and to begin to introduce

effective chw strategies to the care modelshere to get better outcomes. we know that asthma can be prevented in manycases. it can be better managed. we also know it's highly serious. in talking with debbie before the sessionstarted, she mentioned that two students in her schooldistrict died in the last five, six years from preventableasthma. there are serious asthma disparities and there'sa lot we can do better. with that focus on equitable and optimal outcomesfor all communities, that's what we're about.

i'd like to introduce our guest presenters,our faculty for this morning. i'm so delighted that we have dr. megan sandeland anne walton from boston medical center joining us. a few words about each. megan is a physician with a master’s ofpublic health. she's a pediatrician at boston universityschools of medicine and public health, and she's also medical director of the nationalcenter for medical legal partnership and co-principle investigator of the children'shealth watch. she has expertise as a clinician, as a researcher,

and especially as a nationally recognizedexpert on housing and child health. she has written numerous peer reviewed scientificarticles and papers on how housing affects child health. she's also served as principle investigatorfor numerous nih, hud, and foundation grants, working with the bostonpublic health commission and the massachusetts department of publichealth to improve the health of vulnerable children,especially those with asthma. joining megan is anne walton. anne is an rnand a certified asthma educator. she's the asthma care coordinator and researchnurse at boston medical center

where she's been involved in asthma researchand programming since 2009. her work has focused on community health workerasthma home visiting programs and asthma education in community based healthcenters in primary care. in that capacity she's developed a comprehensiveasthma training program for chws and a chw supervisor training program. she has a background in critical care nursingand health education. prior to her work at boston medical centershe coordinated educational programs for parents of children with asthma and allergiesfor the asthma and allergy foundation new englandchapter.

please join me in welcoming megan and anne. when we think about the program objectivesoverall for this morning, we're hoping that we'll increase your familiaritywith the community health worker role, really theirfunction, and the results and value that they can haveparticularly in the area of healthcare reform. we're going to specifically focus on asthma. we could have this discussion about diabetes,cardiovascular, and others, but we're really going to focus on asthmatoday. i think we're going to learn about a bunchof different models.

we're going to describe the model that we'reimplementing at boston medical center, but we're also going to be discussing othermodels both from public health departments, from more homehealth agencies and other things that have been done acrossthe country. i think that we're really going to explorethe question of related to outcomes teamwork, the training, and the supervision, and theintegration, and then finally try and address a littlebit about funding. those are our three goals. you can see howwell we meet them by the end. please interrupt with questions. this is meantto be interactive.

we're not here to talk at you. we're goingto talk with you. with that i'm going to take a little bit ofan audience survey. i want to get a sense of who's in the room. what are the different roles that people playin the audience? audience: asthma specialist. megan: asthma specialist, great. audience: community health worker. megan: community health worker, great. audience: nurse. program manager.

megan: program manager. audience: school nurse. community health worker. megan: another community health worker, great. audience: school nurse. megan: school nurse. public health departmenti heard, yeah. audience: asthma care coordinator. megan: asthma care coordinator. we've got asthma specialists, some communityhealth workers, program managers, school nurse, public healthdepartment, asthma care coordinators,

nursing student, health plan based people,and then home agency based people, american lung association, er physician. audience: nurse. megan: nurse. thank you. er nurse, but goodtoo. that's awesome. all right. this is great. this is a really nice audience mix, and i'mhoping we'll be able to tailor our discussion so that it's going to be useful for all yourdifferent levels. i'm going to start first with, in some ways,why we're here. i live in massachusetts and have practicedthere

and i think the burden of asthma in massachusettsis pretty significant. i think it also is pretty significant in minnesotaand this idea of the rising levels of asthma. the most recent comprehensive survey we haveis from a few years ago where one in ten people in massachusetts,close to 10% of adults, and about more than 10% of children have asthma. the hard thing here is that when we look at the behavioral risk factor surveillance survey,or brfss as some people call it, b-r-f-s-s, they will look at who would beclassified as not well controlled, or who would be classifiedas poorly controlled.

when you collapse those two categories together,like 75% of adults are either not well controlled or poorly controlled. 65% of children would classify into that. we know that not only do we have increasingrates of asthma, but we have increasing uncontrolled asthma, and that we're not moving that dial enough.right? i think that what's really clear is when westart thinking about those gaps of care, we know that those numbers are even worseamong black and hispanics in our state. when we think about that, that's a consistentlyhigh rate of hospitalization

so not just not well controlled asthma, but ending up in the emergency room in thehospital. really trying to think about what's the wayto really try and address that. when the massachusetts department of publichealth founded its asthma office in 2009, one of its maingoals was actually to use community health workers as a way to address disparities. you'll hear anne and i talk about the readystudy, which is r-e-a-d-y. right? it's reducing ethnic and racial asthma disparitiesin youth. we really wanted to focus on young kids.

we started at first at two to eleven at tryingto reduce those asthma disparities through a community health worker model. i'm going to start with what is a communityhealth worker. i actually want to here what people's impression. we have a couple community health workersin the audience. what is a community health worker? who is a community health worker? what arethe key things you would describe? audience: somebody from the community. megan: someone who actually is from the community.

absolutely. i was going to say not only fromthe community but perhaps having cultural and linguisticcompetence. right? because they're from the communitythey may be able to have that knowledge. it is really interesting we're going to talkabout the history of community health workers. right? in some ways we'll talk both about the designation, the professional designation, which has reallynow been recognized by the bureau of labor as an actual professionaldesignation, but then also thinking about historicallypeople have been

community health workers probably for centuries.right? in terms of it and being able to acknowledgethat. absolutely. i think that one of the key thingsthat sometimes people will talk about is community health workers and their training. with that i'm going to actually have anne,turn it over and talk about the history of community health workers andsee if we can bolster that definition. anne: as megan said, the role of communityhealth worker actually dates back to the 17th century where people were chosenfrom the community and it was a position in society that waswell respected.

it was generally the go-to person who hadinformation about healthcare, had ideas about what to do, where to go forhelp, and helped people to understand how to accessthe resources. it's not very much different than what itis today. the american public health association, i'mnot sure when this happened, megan might know, has a clear definition ofwhat a community health worker is. they say that it's a trusted member of ordeeply understands the community served. they act as a liaison between health and socialservices and the community. they work to build individual and communitycapacity by doing outreach,

by doing community education, sometimes theydo some informal counseling, they understand social support networks andhow to access those, and they work as advocates but they also workto help people self advocate. that's really important. what's really distinctive about a communityhealth worker? i hear often, "what do i need a communityhealth worker for?” “why do we need one more person on the team?what can they possibly add?" i think it's important to recognize that therole of the community health worker is a very distinctive role. they generallyare not providing clinical care.

i hear physicians and nurses say, "well whatare they going to do?” “i'm the one that's prescribing. i'm thedoctor. i'm the nurse." that's not what a community health workerdoes at all. a community health worker primarily worksat building a relationship, a trusting relationship first and foremost. by doing that they can relate to the community partially because they're of the community, they speak the language, they understand thehealth practices and the cultural practices, and so once they've built that relationship

they can work to help us to reinforce whatphysicians order and what nurses teach. i feel like they're that missing link. theyunderstand the culture and are perhaps better able to recognize whythere's that disconnect. why do we give prescriptions? why do we hand out spacers, and then findout that the child's in the emergency room? why are they not following our instructionsat home? everything's good. i've covered this. i'vecovered that. i've covered the next thing, but yet something'snot working. i really see them as that missing link.

they generally do not hold a professionallicense. that defeats the purpose in some ways. you want them to be viewed as one of the group. there was a study done that looked at eightpublications of community health workers and it was published in the journal of asthma. the focus was low income urban communities. they were looking at how chws could improveasthma with regard to the environment. chws were really found to be very effective. again, chws can be the eyes and ears of thephysician and the healthcare team. they can see things in the home, and i'm surethe community health workers

that are in the audience can verify this, that we're never going to see unless we gointo the home. oftentimes those things that are in the homeare the biggest barrier. it isn't always transportation or the thingsthat we might think of. not accessing insurance or funding for whatthey need. sometimes it's the fact that asthma is thelowest rung on the ladder in terms of their priority. by having a communityhealth worker go into the home and actually visualize what's going on becausethey have that relationship with the family, they're going to almost becomea confidant.

they're going to hear things that we're nevergoing to hear. we were at dinner last night and one of thephysicians at dinner said that she has trouble sometimes with full disclosure, because shehad a dad come into the office and he was embarrassed because he had recentlygone through a divorce. he didn't know what was going on with thechild's asthma. people come to our offices and they have acertain amount of pride. they don't want to say they have ceilingsfalling in and water on the floor and roaches roaming. the community health worker is a really importantpiece i think of the asthma care team.

in massachusetts we have a comprehensive outreacheducation certificate program which we're fortunate enough as megan mentioned,it was funded through the department of public health and it was developed and implemented throughthe boston public health commission. it's a comprehensive core program that offersseven separate trainings. i think it's eight days or nine days. it'spretty intense. people who are in these trainings learn aboutassessment skills. they learn how to look and pull out the importantinformation from a home visit. it doesn't always have to do with asthma,honestly.

they learn about public health and the importanceof living in communities where there is a level of wellness. they learn some leadership skills. not to come in and bulldoze the family intodoing what they think they should do, but rather how to gently guide a family todoing what we hope they'll do. they learn about cross-cultural communication. the importance of taking what they learn inthe home and translating that to their supervisor inthe medical home in a way that isn't, "i said to do this, and the patient won'tdo it."

to bridge that gap between the cultures. they learn a lot about the whole process ofoutreach in the community, the nuts and bolts of doing home visits. the training emphasizes three specific skills. conducting educational sessions either ina community based program in various cultural groups and also individualsettings, obviously the one on one with the home visit. it emphasizes expanding proficiency to providinginformation and referrals on a range of health topics.

i'll get into a little bit later the specificsof asthma training. this training is really just the overall nutsand bolts core training. it prepares the chw once they've got the etiquetteyou might say of community health work, then they go intothe disease specific program. there's a huge emphasis on taking the healthmessages that come from physicians and nurses, and sharing them andshaping them in a way that is going to be listened to. we don't want our messagesto fall on deaf ears and part of that has to do with how we presentthe message. for us in our program i think that we reallytry to match up the culture of the family

with the chw. we have a large hispanic andlatino population and haitian creole. we have a community health worker who's haitian and we have one who's actually puerto rican. when they're going in to the home it's muchdifferent than if i were to go into the home. i think that i would get much more resistanceand much more skepticism thrown in my direction than they do. issues do come up. we had a family just recently where the husbandhad recently been deported to his country of origin,

and the mom was very concerned that they werelooking for her too, that if they gave too much information theywere going to come out and get her. the community health workers, because of theextensive training that they get, they're really able to say, "i understandyour concern.” “but while i'm here perhaps we can talkabout that and i can look into getting you some reassurances, but let's talkabout asthma." with motivational interviewing skills andvarious ways, they're trained to, not to say twist the conversation, but turnthe conversation in the direction in which they want it to go.

that's why sometimes when we go in for asthma,asthma is not what we talk about. in massachusetts as well with the fundingfrom the dph and the support of both dph and the boston public health commission, we've developed a supervisor training programas well. the supervision training addresses qualityassurance. it says three and there are actually fourthings, but it does address three: quality assurance, communication and information, and creating a supportive environment. inmassachusetts, community health worker supervisors are generally licensed practitioners.they can be a master’s in public health

as well, but there's a big push to have supervisionby a licensed person. one of the questions that has come up is how do i know that the community health workersare doing the right thing? part of that is dependent on the quality oftraining that you have. as a supervisor myself i do observationalvisits. i meet with the community health workers oncea week. i only work two days a week, but my phoneis always on. we text, we email. i pretty much know whattheir patient caseload is. if there are any issues they know to callme.

also, i went through the training that thecommunity health workers do for core training. i participated in developing it. i want to be there to see the way the communityhealth workers responded to the training. i think for supervisors tosupervise well it's important that they understand the role of the personthey're supervising. in massachusetts, the supervisors, through oneof the programs that megan is going to talk about a littlebit later - it's a collaborative - they have come not only to the supervisortraining, but they've come to the regular core trainingand the asthma training.

the supervisors know what's going on. certainly for me, when i first heard of thecommunity health worker model, i immediately went, [slaps head] “anotherperson trying to take my job.” i'd been a nurse since 1976 and i was toldthat if you didn't have this degree you were out the door. if you didn't do thisor that or the next thing. i'm still here 30 some odd years later. i quickly learned when i began to understandthis model that that's not the case at all. community health workers do something i cannot do. i am not capable to build that relationshipwith the cultural sensitivity

that is required in a home setting doing visitslike they do. in minnesota here it's a little bit differentand joan can step in if she'd like, but in minnesota you have a standardized competencybased education which is based in the higher education communitycolleges, 14 credit program. it's classroom. it's field based. it's a certificateprogram. there's a lot of on the job training, andwe do that as well. we mentor. the more experienced communityhealth workers work with the less experienced. they observeeach other. they go on their first visits together sothey see how each other works

and communicates with the family. there'sa lot of on-the-job learning as well and that's a big component of the minnesotatraining, and continuing education, which hopefully isacross the board. supervision varies depending on the area ofpractice, the setting. community health workers who are working ina government agency, according to the statute, are required tobe supervised by medical physicians, advanced practice nurses, dentists. whichwas really interesting for me because i'd never heard of a community health workerin the role for a dentist practice. then one of the community health workers thathad dinner with us last night

was saying a lot of her patients have dentalcarries. i could see that would definitely be a beneficialuse of community health workers. i'm going to turn the show over to joan totalk a little bit about the minnesota community health workeralliance, and how they work with their supervisors andprovide resources. joan: thanks a lot, anne. i'll just add afew words here to give you a spotlight on our minnesota chw building blocks, and it's something i hope all of you in thisroom will take pride in because minnesota is one of the recognizedleaders in chw field development,

field building. what does that mean? it meansthat a group of folks very much representative of the kinds of peoplein this room got together a decade ago and together with chws, withhealth department representation and representation by nursing and health plansand community based groups and a wide range of partners, including educators, first developed a scope of practice for chwsthat was based on an understanding of the chw role that reflects three things. chws have a set of attributes. they have this shared life experience withthe people they serve

which can be defined around ethnicity or raceor health condition. being a veteran for example would be a sharedlife experience, so again this can cut across many differentways. then of course training. the training that was built on this scopeof practice is competency based, it's a state-wide program, the only one inthe us to date, and it's offered in higher education. whywould that be? because we really wanted to make sure thatwhat we built here in minnesota would be an educationalpathway for chws and not a dead end.

the program is currently offered in a networkof seven schools, some community colleges. st. kate's offers the program here in saintpaul where it's stand alone or part of a bachelor's degree program. it's also offered by summit academy in northminneapolis. it's offered in rochester and in bemidji andin mankato. so we have some greater minnesota sites as well. it's available in face-to-face format by andlarge, but our programs in mankato and in bemidji are either online orhybrid online, in person. scope of practice, standardized educationin post secondary schools

leading to a certificate, and then that certificateis recognized by our minnesota department of human services, that'sour state medicaid agency for specific chw payment. not the totality of the rolein all its many places where it can be helpful, but in provider settings in a wide varietywhere there's clinical supervision, and those can include clinics, dental offices,local public health, indian health service, hospitals. the visits can occur in an institutionalsetting. they can occur in the home. they can be carried out in the community.they can be one-to-one or they can be in groups. there is actually medicaid payment for thatdiagnostic related patient education. there are other functions that chws providethat are very, very important,

but they're not all covered, but the significantpatient education piece is. just as anne said, clinical supervision isvery important. chws are parts of teams and that assuranceof training and supervision is really critical. the other thing i want to mention and i'llget to that question in a second is that we offer through the alliance a chwsupervisor's round table. bonnie carlson from saint paul ramsey healthdepartment is here and is an active member of our group, and we meet in personor by phone every other month. it's a chance for chw supervisors to growin their role, become stronger supervisors. they're in a unique position because the roleis newer to a lot of mainstream provider

organizations, so this is a great opportunityto share lessons, share challenges. anyone here, i would love to have you jointhe alliance and if you're interested, join the supervisor'sround table. know that it's a resource for you going forward. two questions. one is about the duration ofthe training. what does 14 hours relate to? the training typically is accomplished acrosswhat would be a semester of work on a part time evening schoolbasis, or it can be accomplished as st. kate's hasoffered it as a program across a full academic year that meets two days a week acrossa whole year. it's intensive.

it's foundational training. we call it theliberal arts of the chw field. if you're a physician, you've had your medicalschool training then you will specialize if you so choose. if you're in nursing youhave your basic nursing training and then likewise if you're going to go intocritical care or go into public health you'll have on top of that additional training. this is generalist training. keep in mindwe're a leader so all around the united states there are very few states that have this kindof training, and other states have been interested in ourtraining and folks from our education committee have gone out to visitwith other organizations

that want to learn outside of minnesota whatwe're doing. now the chw role is a relational role. right? face-to-face, coming from the community, soonline is not for everyone. we're the first to say that. it's the tension between wanting to providechw training, provide access to the chw role in greaterminnesota. i do remind our folks from new england youcan fit the entire state of massachusetts in st. louis county. okay? we have a lot of rural areas and we also havediverse populations and communities

all across our state. we have, as you know,native american reservations, tribal nations where there's the chr role,it's a chw type role. very eager for this training as well. that's something we want to be really carefulabout. our faculty at the two schools that offerthe online do talk to students about that, and the bemidji program offers, as i said,also the hybrid, so there is some face-to-face as well. it's balancing that need with the importanceof the relational role. i'm going to step back, and feel free to visitwith me at the break

or afterwards if you want to learn more aboutour minnesota building blocks. anne: i just want to speak to the issue ofinternet or online study. i have a son who has dyslexia and a learningdisability and he does his best learning online. i'm an auditory and a visual learner and soi like to be present and interact, and i think it's about balance. it's about understanding that people who trainonline do need to come and do some role playing with motivational interviewingand with hypothetical situations and work things out. i don't everthink it's an all or nothing situation. megan: transitioning more into this idea ofa professional designation. right?

what's been established? we talked about the history of chws, the specificroles, how do you train someone. not anybody gets to put the words communityhealth worker on their resume. right? this is something that someone shouldhave some type of formalized training. i think it's really important to talk aboutthe generalist training, and then specialized training in asthma, andthen supervisor training for the community health worker. there are a lot of differentlevels in terms of being able to say not only are you trained to do this work,but what type of training did you get. the department of labor actually recognizedin 2009 that there's a distinct

occupation code for community health workers. they actually now track this across states.they really identified it in four key areas. assisting individuals in communities to adopthealthy behavior. healthy behaviors is a huge component - thatmotivational interviewing, those discussions. we did additional trainingwith our community health workers around smoking cessation, and thinking aboutway in which they can be trained in that. the second is really conducting outreach andimplementing programs in the community that promote, maintain, or improve individualor community health. this is where we're going to describe in aminute the program that we adapted

from seattle king county, which is a veryrigorous standardized program. you have in your folder a lot of our materials. we have a regimented “visit one you do this,visit two you do that” type of thing. the third is providing information on availableresources, providing social support, informal counseling. that's where a lot of times community healthworkers are really doing a lot more than just the education you're asking themto do, and really helping families connect to socialresources: food, energy assistance. things like that. identifying and advocatingfor individuals and communities.

i think to hear our community health workerstalk about how proud they are of people learning to problem solve on theirown so that it's not that you continue to needthe community health worker, but that people think about it. we talk a lot about the asthma action planand the community health workers will take pictures on their phone of the asthmaaction plan being up on the wall or being up on the fridge and things likethat. being able to start to really utilize it. i want to stop for just a second and talka little bit about healthcare reform

and opportunities. the patient protectionand affordable care act did actually acknowledge community health workers. it actuallycalled out that they were recognized and important members of the healthcareworkforce. then really acknowledged that there's a lotof evidence around how they improve health, access, outcomes,strengthening healthcare teams, enhancing quality particularly for peoplein poor and under-served and diverse areas. the summary of this is from a health affairsarticle in july 2010. i think in massachusetts we're a little bitfurther ahead of healthcare reform because we started it a little bit earlier.

i'm going to just take a minute to talk abouttwo opportunities that we're currently exploring. actually three that we'reexploring around long term funding sustainability. the first is what'scalled the bundled payment. how many people have heard of the word bundledpayment? right? a couple. this is the idea that instead of being ina fee-for-service world, so if you come to the doctor you send a billto the insurance company and they send back a fee. right? we're going more into youhave patients who are registered in your practice and you get a payment eachmonth to basically manage their care.

honestly it's really capitation, just calledsomething different. the idea is that you bundle with that paymentan additional fee for asthmatics. you get an additional amount of money eachmonth to manage your asthmatics. part of the ability of massachusetts to dohealthcare reform earlier is we got a medicaid waiver. we got a waiver from thefederal government to actually do innovative practice, to try and get everyoneinsured. and written into our medicaid waiver was this massachusetts bundledpayment for pediatric asthma. it's a 200 page document. one of the pagesdescribes this bundled payment. my understanding is it got a lot of scrutinyfrom the federal government,

but it did get passed. the idea was that, say a primary care practicewould manage their asthmatics with this fee, and understood as part of thatwas that their high risk asthmatics would have a home visiting program with communityhealth workers. it's not meant just to fund the home visiting. it's meant to fund general quality improvementwithin the practice, and then it have within that. four practices are starting this pediatricbundled payment pilot. there are two of them within children's hospitalboston,

the actual hospital itself, and then one ofthe community health centers in boston, martha eliot, that the hospital runs, tuftsmedical center, and lowell community health center are thefour sites that are going to be piloting this. the second area of funding is that massachusettspassed its original healthcare reform legislation in 2006 and then passed an updatedversion in 2010. during the update they actually wrote in somethingcalled the prevention wellness trust fund. this is basically a tax on hospitals thatthey pay money into this trust fund to do prevention. it's interesting. the legislaturewas really focused on prevention

for things that would pay off quickly. they required that there would be a returnon investment for prevention. which, any of you in the public health worldknow, is hard. the bar of what got to be included as prevention- they chose four topic areas. one was tobacco cessation, which has beenshown to pay off. the second is preventing elderly falls, whichhas also been shown to pay off. the third is cardiovascular disease. the fourth was pediatric asthma. communities could bid that they were goingto be part of

the prevention wellness trust implementation. they had to choose two of the four areas ata minimum. six of the communities actually chose pediatricasthma as part of their pilot. again, it includes both the idea of qualityimprovement within the clinical practice and included asthma home visiting with communityhealth workers. we're actually kicking off a learning collaborativenext month between the six cities that are going to bedoing this plus the four bundled payment pilot sitesto create the platform for understanding the implementation, the funding streams, andothers.

pam made a good point that we need to makesure when we're costing it out, it's not just for the community health workersalary. it's for the supervision time, it's for theadministrative time and other things. audience: it seems as we're going throughthis, that this is a job almost a public healthnurse used to do. megan: yeah. the question was, i'm repeatingit for the camera, around the idea of isn't this really what public health nursesused to do? i think there's no doubt in some ways we're- i don't want to say reinventing the wheel - –

but we're redesigning the system to deliversomething that traditionally was there. i think that the reality is that you don'thave enough public health nurses. right? that's my understanding and correct me ifi'm wrong, but the idea is thinking through ways in whichto design a system in which you could utilize the public healthnurse and use a community health worker as one of the extenders for thinking throughit and really complementing the public health nursing. it's not replacing. let's be honest. we're not talking about publichealth funding here. we're talking about healthcare funding, right?

we're talking about the idea of using a healthcaredollar to do what is essentially a public health mission. when we think aboutthe disparity of funding - in this united states we spend $8,000 perperson and we get really bad outcomes. we are – out of 34 industrializedcountries we're like 26th. we spend three times as much as everyone else and we get literally among the worst outcomes. part of it is because we have not had healthcareembrace its public health mission. we have not thought about ways to deliverpublic health interventions through a healthcare dollar.

in many ways when we're thinking about this,and i'm going to transition a bit to talking about the evidence, because fora healthcare dollar they have to think about it the same way they think about pharmaceuticalsand other things, so we're going to talk about that. i will also talk about some of the models. there's not just one way to deliver this. we're going to describe how we do it at bostonmedical center, which is where anne is the supervisor. shepredominately stays in the office. she does limited supervision. from a qualityassurance point of view

she goes on 5 to 10% of the home visits tomake sure that the community health worker is doing the job, but she's not there allthe time, so i want to be clear about that. i'll talk about another model called harp where it's a three-visit model, where thefirst visit is done with the public health nurse and the community health worker together, and then the community health worker doesthe follow up. that's another way to try and think aboutit. the third way that in massachusetts we'reexploring long term sustainability is through a case rate. this is an idea thatit's still the fee for service world exists.

just like when you get a surgery you get acase rate. you get an amount of money, a lump sum, andyou deliver a service within that lump sum. we are currently trying to negotiate withinsome of particularly the medicaid managed care plans a case rate for deliveringthe service. for us the four visits, home visits, withthe environmental goods and other things – i think that it's another way to try and fundit. i think the population based - the bundledpayment is where the future is going, so i'm not convinced we'll need a case rateforever, but it may be until those are reality fundingstreams.

we're going to negotiate both sides. i do think that there are very different modelscoming down the pike around global payments, and you have to live within thatbudget, versus more of these risk contracts, where you get an amount of money and you arehoping that someone doesn't come to the hospital. thepharmacy side of things is very different. i will say just as an aside that pharmacyis something that i always find fascinating. right? we don't blink at the $1,000 pill.we don't. hepatitis c is the latest example where theyare literally paying millions of dollars monthly for a $1,000 pill. right?

what i think is important, and we're goingto talk about the evidence, is the sticker shock around what it coststo do four asthma community health worker visits with nurse supervision, with a vacuumcleaner and other things. it tends to be about $1,300 when you startfull case rate. it's a lot. people will sit there and go,“oh my god, it's too much. we can't possibly do it,” and then they won't blink at paying $1,000. this is where the interesting thing is. there's really good evidence of the persistenceof this effect. the inner city asthma study published whatis very similar to a community

health worker model - $1,500. and they showedfor two years a persistent benefit. that's a great pill right? you would pay forthat pill every day of the week, and yet when we say that it's somebody comingto your house and giving you a hepa vacuum, we won't do it. i want to push back a little bit about thecost because i think that we hold different standards. i'm going to get back on trackand i'm going... anne is looking at me. the barriers to asthma control. what are some of the barriers that you guyssee in your practices?

audience: access to medicine megan: literally just not beingable to access medicines. what else? audience: i don't know if they encounteredit, but teaching moments at the clinic. when there is tons of that. megan: yeah. a lot of misinformation around whatthe medicines are for or other types of things. what else? audience: i think sometimes literacy skills. megan: yeah. i think health literacy is enormousin trying to think through ways in which to address it.

you guys got most of them. cultural health practices - so sometimes peoplehave very deep beliefs that other things are working. for some ofmy latino patients, menthol is something you slather on everythingand it's really important. being able to understand that and not viewingit as an “either or,” like i'm either going to use the inhaler orthe menthol. this skepticism around “i'm not really suremy kid has asthma,” certainly barriers to accessing healthcare, really minimizing the risk of poorly controlledasthma,

a lot of misinformation about asthma, worries about sometimes inhaled corticosteroidsand whether or not those will actually have long term side effectsi think is really important. a lot of social challenges. you're worriedabout housing. you're worried where your next meal is coming. taking that inhaler is just not as high onyour worry budget in terms of thinking, and then certainly language. both literacyand literally linguistic access i think are really important. anne: i would just like to share a littleanecdotal story

about some cultural health practices and skepticism. we recently had a haitian family who kathleen,our haitian creole speaking community health worker, visited. and she haddone the second visit and she was finishing up and the mom saidto her, "well, you know i think it's fine that you want to come, but i don't reallythink he has asthma. anyway we're going to haiti and he's goingto drink the blood of some kind of lizard." their practice is that there's some particularlizard that is prevalent in haiti that they take a teaspoon of blood and they have thechild drink the blood. their asthma is supposedly cured. now youcan imagine that if that was something

that was said to me my face would have saidit all. kathleen said, "well ok. when are you planningyour trip, and could we schedule our third visit after you come back?" she didn't miss a beat, and i think that'sone of the clear benefits of having a community health worker. megan: yeah. i think in a lot of ways it'sbeing able to be more comprehensive about trying to address a lot of those barriersi think can be important. i'm going to start diving into some of thechw models. please ask questions if there are things thatare important.

the first one is the ready study which i introduced, it’s reducing ethnic and asthma disparitiesof youth. this is where we have clinical sites who willrefer either poorly controlled or really severe asthmatics. we typicallywill both identify them through clinic referral or through a hipaa waiver to be able to lookat our er list and our hospitalization list. we can actually approach families directlyor we can receive a referral from their clinician. we typically do between four and five educationalvisits with a community health worker. we began first where we did the asthma assessmentat the first visit and the environment assessment at the secondvisit, and then did three follow up visits.

we've now with a second round of funding collapsedthat to do the asthma and home assessment at the firstvisit and then three follow up visits. we really try as much as possible to makethe asthma action plan the cornerstone of our asthma teaching. one of the things that we require of sitesthat refer to us, or that we recruit from, is that we have access to the medical recordsso that we can get the asthma action plan. anne is credentialed at both boston medicalcenter and three of our community health centers in boston, so that she cango in and get the asthma action plan. then we really focus not only on asthma control,

but we also focus on environmental control. those two are not “either or,” but they'rereally viewed as both. we do provide low cost asthma supplies. wedo include a hepa filtered vacuum cleaner. we do mattress and pillow encasements fordust mite control. we do a set of natural cleaning supplies, sothese are things like baking soda or vinegar that we actually givethe patients with “green,” make your own at home cleaningrecipes. then we do a pest control kit. a garbage can with a top on it, some copperwire gauze you can stuff into holes,

sticky traps or other things, and really large zip lock bags to help peoplewith storage so that they can store things in their homewithout it becoming a harbor for pests. we also offer a lot of assistance and referrals. things like housing code inspections, tobaccocontrol. things like that. then our nurse asthma educator anne is thesupervisor for the program. we do a lot of key measure that you wouldthink of as urgent care use: number of exacerbations, we do an asthma controlmeasure based on two week recall of symptom days, rescue medication use, nighttimewakening or activity limitations,

we have a pediatric asthma care giver qualityof life score that was developed by dr. elizabeth juniper. we also look atenvironmental control measures. the community health worker does a walk throughat the beginning and at the end of the study to show we've made reductionsin the asthma trigger score. that scores six different asthma things: pets,pests, tobacco, dust, mold, and i believe clutter. we also do a competingpriority scale trying to get at whether or not people are able to change some of theirpriorities around kids’ asthma. some of our preliminary data is really good, and as i said we adapted our model from theseattle king county model

where we were able to show very similar resultsto what they were. huge reductions in symptom days from 4 daysout of 14, to 2 out of 14. asthma control level improved across the board, so not everyone got to the well controlled,but we moved a lot of people from very poorly controlled to not well controlled. er visits, hospitalization, urgent care use- a lot of different reductions. one of the nice things is this idea that ithink there's a lot more than just the symptom days. i think the caregiver qualityof life becomes really important, and so our pre score was actually pretty low.

if people aren't familiar, it's a scale ofone to seven, and so when they did this caregiver qualityof life score in seattle, most people were a five and then they movedthem to a 5.6. ours actually started at a 4.3 and we wereable to move them up to a 5, like a point difference is actually quitesignificant. this is things like feeling helpless, familyneeded to change plans, feeling frustrated, sleepless because of kid'sasthma. another model that was developed by elizabethmcquaid in providence, rhode island was this harp, home asthma response program.

this is a collaboration between st. josephhospital and community asthma programs at hasbro children'shospital. they've had a variety of different funding. we had funding for the ready study both fromnih and hud actually has been a funder of ourswith the mass department of public health. they got some rhode island department of publichealth funding and then also recently we're both part ofa center for medicare and medicaid innovation award, a cmmi award as part ofthe new england asthma innovations collaborative. harp also focuses on youngchildren, on kids down to age two.

after an er visit with asthma, they also followhome visits. i think what's interesting is they do a three-visitprogram where visit one does include the rn asthmacertified educator, and then the subsequent visits are with thecommunity health workers. they also provide supplies. the hepa filtervacuum, the bed coverings, the asthma friendly stuff. i should say that we don't actually necessarilydo allergy testing. we don't ask people, "are you dust mite allergic?"and then only give to those. we do it universally, which is consistentwith how it was first implemented in seattle.

they have also really nice outcomes. what's interesting is a lot of the peoplethey initially met did not have asthma action plans, 77% of the people coming through the er. they were able to show that by the end over80% had an asthma action plan, reductions in daytime and nighttime activity. they've been actually starting to do a returnon investment analysis. what they've shown is that for every dollarspent on the intervention they actually will save over two dollars inthe healthcare system. children's hospital in boston did a similarone where for every dollar spent

they saved $1.40 to the healthcare system. more and more this is not only showing thatit's effective in terms of better health, but it actually may save money as well. i wanted to just highlight our boston publichealth commission has been a real leader in the community healthworker movement. they began a boston asthma home visiting collaborative. we're blessed to have a bunch of differenthome visiting programs: boston medical center, boston children's hospital,other community agencies that are doing it. what they really wanted to dowas create a place for collaboration

where the home visitors could come together,talk about different common barriers. they wanted to be able to standardize someof the educational messaging and be able to think about it. they wantedto think through - in the city of boston we have a lot of different capacity issues. haitiancreole and spanish are two of our languages, but we also need to think aboutchinese and cape verdean creole and portuguese and hebrew or russian or chineseand all these different things. they've been really thoughtful about gettingnew funding sites so that they could have increased capacityacross the city. then when we think about complimentary homebased services

it's not just the asthma home visiting, beingable to do the trainings, being able to have them available or otherthings, but we also started the boston breathe easyat home program, which is a collaboration between healthcaresites like boston medical center, the boston public health commission, and thenthe inspectional services department, the code enforcement agency in boston. what we created was a web-based referral system for either if the community health workergoes to the house, or if i as a physician am talking to a family and they disclose tome that they have pests or mold in their house,

i can refer directly to code enforcement andthen get email updates about how the case is going. being able to think aboutthe complimentary home services to make the home visitors more effective hasbeen really helpful. yeah? audience: what happens with people who areundocumented? megan: there's a lot of fear among the undocumentedcommunity about any type of enforcement. right? i thinkthere are two things. one is we've done extensive trainings withparticularly the inspectors around the idea that the breathe easy at homeprogram is not families calling to report,

it's their healthcare provider calling andsaying that this is something that makes them sick. they actually include a flyer around retaliation, and the fact that if there is retaliationfor a family that they actually are able to access thelegal service system or others. the other thing is, as part of the breatheeasy at home we have a flyer developed by our medical-legalpartnership. how many people have heard of medical-legalpartnerships? okay, so not that many. medical-legal partnership is really a healthcaremodel

where you integrate legal services as partof your healthcare team. bringing particularly a legal aid attorney. someone who understands the law particularlythings like housing law or benefits or education law into the healthcaresetting so when you detect that someone has a legal need, you're trained tobe able to detect that, you then will have easy, one-stop shoppingaccess. our medical-legal partnership - it's actuallyavailable on the city of boston's website, if you google city of boston breathe easyat home you'll come up to our website page. we have a flyer developed for this very questionin terms of healthcare providers

feeling confident that if they're referringsomeone that – i can't say there's never a risk associatedwith it - but that there really have been no reported cases of someone being reportedby their landlord to the immigration and customs enforcementagency, ice. just trying to help families think throughhow to access what their legal rights are without fear of retaliation. these are thelists of the boston asthma home visiting collaborative. the public health commissions, boston children's, boston medical center, the environmental protectionagency in region one has been really supportive of this and providedsome seed funding for this.

we have health plans like neighborhood heathplan that come around the table. partners asthma center and tufts, and tufts was important because one of thereal gaps was the chinese-speaking community, so we were able to actually trainasthma community health workers. then tufts was able to then bid on this bundledpayment pilot project because they had that capacity built in totheir clinic. what they do is monthly meetings where it'sreally about a support network. right? these are asthma home visitors thatcan come, receive some asthma education, be able to discuss difficult cases, be ableto learn some problem solving peer-to-peer

support and other things. the goal aroundit is standardization of service where people may deliver the asthma education slightlydifferent, but the common set of messages have all been agreed upon. when we think about that, it's a really nicerole for a public health department to play in terms of how to sustain these programsand standardize and ensure a certain amount of quality. this is the onepicture of the groups of the community health workers. i love them. the last one is there are some models outthere around having clinic-based community health workers.

so the two or three models i've presentedso far have been very much home based. you go and you do everything in the home andit supervises back. i forgot to mention that part of the readystudy is that we actually put updates in the electronic medical record. after every visit the community health workers,often during the visit or right after, will upload what the findingsare onto an online system. we actually do everything via an ipad thathas 3g access, it goes into a web-based data collectionsystem called redcap, which is free, and you can literally put all the information.

anne then reviews the case records and thenis able to put an update into the electronic record so that the physicianwill see a ready visit just happened, this is what's happening, how many symptomdays is going on, what was done, and other things. what's interesting is that there are somemodels now, tyra bryant-stephens children's hospital philadelphiahad a home visiting program that she's recently brought more into theclinic as an asthma navigator program. we're piloting thinking about a similar programat boston medical center based out of our pediatric pulmonary clinic.

the thought here is that you would have someonewho can follow up with someone after the clinic, use the community healthworker, but still have the ability to go into the house, and be able to have that personsupervised by an rn-ac to do that. i didn't mention, because we have an er nursein the audience, another model is the impact dc program, which is stephen teachout of children's national where, when kids come into the emergency room, they'reenrolled in the impact dc program so that the community health workeractually is part of the er department. because the primary care network in dc ispretty frayed. and they have really, really nice documentedoutcomes in terms of referrals and success.

it’s a great model in the sense of, howdo you fill the disparity gap. right? i think minnesota sounds like it’s muchmore advanced in the health home model. that’s not the ideal, right? ideally you’dget people to a health home. but i also think it’s interesting to think about differentplatforms of care. to think about it. we don't enroll everyone that we approach,let's be honest about that and part of that is reaching people. we will pull the er list or the hospitalizationlist. oftentimes, especially if someone has beenhospitalized, we don't approach them right away because they are pretty overwhelmed

and we may approach them a week or two laterafter the asthma hospitalization. and so once someone is reached and agreesto be scheduled, we do have then a no-show rate for home visitingtoo. we have done protocols around you have to confirm the night before or themorning of because it's incredibly hard for the communityhealth workers to drive out to the house and then no one behome. we make a policy around, if you are schedulingthat you do have to confirm before the community health workergoes out to the house.

the “do not keep appointment” rate atboston medical center can be quite high. it can be thirty or forty percent in someclinics. i would probably think that we have the sameno-show rate where you are not able to confirm the appointment. it is a good idea. one of the things that'sinteresting is, for some of the clinicians, i've heard this anecdotally that they likethe community health worker program because they feel like sometimes it's easierfor the family to communicate what's going on between appointments and itsometimes can actually replace the follow-up visit in the clinic. for the family -

the director of the pediatric pulmonary departmentis robin cohen at boston medical center. she and i have talked aboutcomparing kind of traditional clinical nurse case management versus a community healthworker model, that's community based and patient-centered, wherethey get to decide if they want to do home-based follow-up or clinic-based follow-up.they decide if they want assistance with medication delivery to their house, theywant to decide whether or not they need other social supports. and i think when we think about redeliveringcare, we were talking last night about telemedicine. could you even have acommunity health worker in the house

kind of calling into the clinic and makingit easier from that perspective? i think that what is interesting is the... anecdotally, i think the purely clinicallybased community health workers, i am not sure are as effective as the ones that havea home component. i think that is about relationship building and other things. thething that i’ve heard anecdotally is that the patients who are part of the asthma homevisiting program feel more tied to the clinic and actually keep their appointmentsat the clinic more. they're more likely to say, "okay, i know need this. i know whati am going to do. i know what i'm coming in to ask about" and other things.

and they tend to be more integrated into thehealth home, which is an interesting idea that they are getting home based servicesand yet they feel more tied to the clinic itself. audience member: someone was addressing theidea of shame around home conditions. megan: it is really interesting, i’ll repeatit just for the people on the video that they ... there is some shame around kind of home visitingand the conditions, but then there's also sometimes really nice success that happensfast. so chemicals in the home is actually an incredibly common trigger. about90% of the patients, we go into their

home, are using some noxious cleaning agentlike bleach or ammonia or other things, and you’d understand why they aretrying to do it, but those are asthma triggers, right? they may be using an airfreshener because they want to make the home smell nicer. sometimes really simple stuff like switchingto a green cleaning agent and not using the air freshener, they'll see a reallyimmediate difference. we actually had an npr reporter come to the house and that'sliterally what the mom said was, "i didn't believe the community health workerthat it would work, but she told me that she had used it herself and when i usedi,t it worked really well and i

immediately saw that. i haven’t been tothe er since, and i think it's because i am now using this green cleaning agent.” right? i sometimes think... sometimes in medicalstuff, sometimes the medicine they don’t see that immediate response, right?it's partly why a controller is sometimes hard to remember everyday. they may rememberthe albuterol because they see the rescue, but it is harder to see that otherone, but the environmental stuff, sometimes they'll see a difference reallyquickly and that can be, again, this kind of building on success that i think is reallyimportant. audience member: this might be a better questionfor joan, but anything,

any minnesota or metro models for any useof the community health worker now? megan: i'm going to let joan in. i do knowthat they do utilize community health workers as part of the health home at hennepinmedical center, but they are more generalists. they are not necessarily implementinga rigorous asthma program, but i think that is an opportunity, right? it'snot like they aren't part of the health home, it’s that we want to think through what'san evidence-based way to implement them further. yeah. joan: i think it is so interesting that typicallywhat we find is people are very interested in the evidence, the peer reviewedevidence. we have

evidence over a decade. some of it comes outof seattle king county, from doctor jim krieger, a whole series of evaluationsthat he has conducted with successful outcomes for chw models. but we also wantto know what is in our backyard? where is it working, who else is doing this?very appropriate question, glad you asked that. what i am hearing at the alliance - and thealliance is the go-to place for folks who are working on chw strategies - as megansaid, hcmc, through its healthcare home program, has a team of nurse-led chws,and part of their work involves interface with asthma patients, with an asthmaeducator

who i know works closely with doctor gailbrottman. very positive response there. we know the chws who are working through a collaborative agreement betweena mutual assistance association in rochester and mayo health clinic, have beenworking on asthma, again, through health care home, and they work with the pediatricdepartment. then wellshare international, which is a community-based organizationthat has had for the last ten years out of its 30+ history, a domestic programlargely focused on the somali population, has done some more, what you maycall more public health-oriented

asthma education with the somali community. so we have some examples here and there, butwhat we don’t have is really a model that folks can get around and begin to rollout to be able to begin to get better results that we are seeing, for example inboston and other places. what i might add is that this isn’t a sort of an outlieror an unusual model for asthma. that really all across the country we areseeing these models in many cities and in lower income communities, undeserved communitieswhere there is uncontrolled asthma among kids. what are some other examples? well, i justcame back from the american public

health association meeting in new orleans.heard about a fabulous program in new york city at the new york presbyterianhospital, where for the last, i think, almost 10 years, they've had a program calledwin for asthma that utilizes chws, and i think what you are hearing isthat the role is flexible and can be adapted to meet the particular community and institutionalneeds. in that program, chws, when a patient, achild is admitted for in-patient care related to asthma, a chw makes a visit inthe hospital before that patient and family return home, to make that connection, and thenthere are home visits that follow. again, a supervised model. chws are not outthere hanging up their shingles or

working independently, they are wrapped intoteams that are clinically supervised and they are bringing us – as anne said– their unique contributions. chicago sinaihealth, has had a great model, great success. so again, all across the country, we are seeingthese models develop. and, jim, to your question - would like throughthis conversation, build a network of people who would like to introducechw models more broadly to address asthma disparities. megan: it was announced, i think yesterday,that the massachusetts vna is now part of hennepin health. you can imagine almosthaving community health workers

and visiting nurses working together for a package of services particularly if you integrate – no? did i say it wrong? audience member: it is mvna. megan: mvna. sorry, excuse me. trying to thinkabout what are different ways... audience member: minnesota. megan: minnesota, thank you. excuse me. tryingto think about the – thinking about what are ways in which youcould align existing resources and supplement existing resources. i do thinkthat whether or not it is clinically based nurses or whether it is public health nursesor

er nurses or other things, i think that you could have respiratory therapists as supervisors, i think you can have a lot ofdifferent visions of how you would implement them. i do think it will be interestingmoving forward as you think about almost the idea of managing a population,so say at boston medical center we have about 10,000 - 10,000 to 12,000kids in our primary care practice. about 10% of them have asthma, so you imagine1000 kids with asthma and then you start doing risk tiers, where you say,“you are low risk.” because i will say not everyone should have an asthma home visit,right? it shouldn’t be for anyone with a diagnosis of asthma. really talkingabout how do you identify those high risk

kids? is it just that they've been in theer or the hospital? that's one way to identify them. or, are there other ways wecan think about it? they haven't refilled their medicine or they're reallysymptomatic, or they clearly don’t understand things well and we are not reallyable to control their asthma. they are coming in for multiple steroids bursts.there are a lot of different ways you can think about identifying that high riskpool. then you make available to them kind of that. i think we are getting moreand more to what are the fte ratios? what are the full time equivalencies of, okay,you've got 1,000 kids with asthma, we think 150 of them are going to be high risk,so that would be we need two community

health workers to be able to do a 6 monthintervention with them and you kind of roll your case list. i think we will get closerand closer to what's the supervision, because anne right now, on 16 hours, supervisestwo full time community health workers, so it is not a one to one ratio.it is a piece of anne's time with a – being able to supervise them and move it forward. audience member: i am wondering if you havetalked more about any of the school nurse models? megan: yeah. i think that's great. no, i'venot talked about school based models, so i want to thank you for that prompt. andyes, i do that think where you base the

community health worker does not have to bejust health based, right? it definitely could be school based, it could be publichealth department based. there are a lot of different ways in which you can think aboutit. in boston, it's interesting, when they designed their prevention wellness trustapplication, they really zeroed down in actually schools and early education centers, as where they wanted to focus their biggest energy because of thehuge disparities in the zero to four population. we're talking about fourfold ratesamong black kids, zero to four, going to the er for asthma than white kids,right? so what they’ve really done is a lot of that tri-fold linkage:home, school, clinic. and being able to

make sure that you have the asthma actionplan, you've got the medicines on site, you are doing the education, that the teachersget education around understanding the symptoms and being able to make sure thatparents are there. i think absolutely school-based models - andthere are a lot of great evidence based stuff. i also think it's really interesting thatthe rates of school absenteeism among kids with asthma will make your hair curl. i mean,it's really ... it's unbelievable. what i sometimes will talk about is you canhave the best educational reforms you want, if kids aren't showing up, or if theyare not staying long enough in the school, they are churning from one school to another,because their families are, let's say,

not able to work because the kid has asthmaand so they end up being evicted, and then they move, think about that. in someurban school districts, 50% of the kids are absent more than 10% of the year. in someurban schools, the churn rate can be a third of kids. there was one school intacoma, washington, where they turned a classroom of 20 kids over with 56 differentkids churning through that school. it's 179% churn rate. a lot of it can be reallysimple things, like just making sure kids are in good asthma control. i think that ... i am a pediatrician, i am focusing a lot onthe health outcomes, but the educational outcomes may be another way tosell the idea of why an asthma

community health worker - and i like the idea of connecting the school and the home and the clinic together and,again, i think community health workers are a really good work force to help supplementthe school nurse programs. anne: we are going to pick up where meganleft off and i am going to talk a little about the training that we do in bostonand the supervision, and then megan is going to briefly talk about how you canintegrate this program into your setting. in massachusetts, we have a specific asthmatraining session for community health workers. i worked to develop that and i ampart of the implementation of that. it is funded through the department of publichealth - massachusetts department

of public health and implemented by the bostonpublic health commission. it serves as a building block for the comprehensiveeducation that community health workers get that i spoke of a bit earlier.they go through that first and then asthma builds on that training. it is a four-dayhome visiting training. it covers not only the nuts and bolts of asthma, which i will describein a minute, but there is a day and a half that is specifically devoted to environmentaltriggers, how to do some integrated pest management control, and there is a session that is almost a fullday on motivational interviewing, where these are role-play, very, very interactivesessions. as i said earlier, one of the things

that i found really helpful, even though ihad worked to develop the curriculum, was to participate in it. i was able to seehow it worked and to sort of gauge how the community health workers benefited ordidn’t benefit from the program and we’ve tweaked the training based onneeds assessments from the community health workers. we have really tweaked it a fairamount. we also have a two-day refresher course thatis offered annually and in between, based again on the needs thatare described by the community health workers, we have added little trainings.i recently did a medication – we called it an advanced medication training- and it came from a previous

continuing ed training on medications, thati really challenged the community health workers not to say, "oh, he is on flovent",but to be able to recognize that there is a difference in color that’s all veryimportant, but when you are talking about flovent, you are actually reading the labeland saying, “this is flovent 44 or this flovent 110.” so that you are not just relyingon the same things that patients are relying on. theyfound that very, very helpful. we also do - there is a group that meets thatdoes community, excuse me, quarterly support groups. they are also involved insupport phone conversations. they share their experiences. we've had some issues aroundsafety.

one of our community health workers was actuallylocked in the apartment and someone was standing in front of the doorsaying you are not leaving. that prompted us to look at the issue of safety,so we do a lot around safety and at these quarterly meetings they can share thoseexperiences. because hopefully that will be a one of a kind experience. we haven’thad any problems since, but at least they have a sense of ways they can keep themselvesas safe as possible. under development is a mentorship program.we talked a lot about how do you know whether or not the community health workeris doing what you want them to do, and what are the standards and scope of theirpractice? by providing mentorship,

hopefully that will ease people’s minds. and as megan said, observation skills assessment. if you look in your packet, i included inyour packet a page that looks like this. it is a grid. we do four, depending on whichstudy, four to five visits. when i do an observation visit, these are the key pointsthat i keep in mind and they’re visit by visit. you can take a minute to briefly look overthem, but it’s important from the most simple things like making sure that thecommunity health worker is wearing their badge. i would never let someone intomy home unless i knew exactly who they were and they had their credential withthem. to how do i assess whether or not

they did the asthma training appropriately?i don't want to spend a lot of time on that but that is one of the tools we use forsupervision. getting back to the training, if you look,there is a… there’s a checklist and this is just thereto show you what we do at each visit. in order for community health workers tocomplete the visit according to protocol, what they learn in their training is veryextensive relating to asthma. we go over basic anatomy and physiology, they do the act test,they understand the control issues. i heard last night, the rule of two,two night time awakenings with asthma per month, two symptom days per week, or two inhaleruses a year. so simple ways that

they can ask simple questions and get reallyimportant data. we do go over medication and delivery systems.again, this is hands on. they practice, i do demonstrations, we go over asthma actionplans. sometimes i hear, “why do they need an asthmaaction plan and how effective is that really?” i think with anything, itis a recipe. it is a kind of a recipe. it is a go to place. where knowing that ison the refrigerator, as megan said. when a child is symptomatic or getting sicker,the family doesn’t go, "what did she tell me to do? i don’t remember. ohmy." they have a go to. i think that is really helpful. we found that it's been reallyhelpful and the families have

really liked it and have started to... asthe visits progress, they actually start to refer to it. at first it’s like, "i don'tneed one because i know what asthma is all about." it takes a little bit of reinforcement. we have the community health workers talkabout flu shots and simple wellness things. keeping their healthy visit appointments,communicating things with their doctors, and feeling okay, not feeling shamed,understanding that wellness is important, and well visits keep you well,you don’t only go and access health care when you're sick, and the benefits of that.good communication: they learn how to contact me if there is an issue. we goover documentation, how to be very

succinct in what they write. megan talkedabout the online program redcap, which is where they collect data. for me onthat checklist you'll see lots of blank lines. that's where they will give me littlebullets of things that are of concern to them. communication is also key in terms of understandingand feeling confident about what they're doing in the field. we talk a lot about sort of reconciling whatour expectation is of a visit and what the family's expectation is. what do the families expect of their child?megan’s done a lot of research on this. if you have a parent who thinks that havinga cough all the time is just the way

my kid is, you need to somehow reconcile that, so there’s a lot of role playing, again, and instruction on how do you bestdo that. we talk about what's available. the resourcesthat are available, such as... megan already spoke about it, so i'm not goingto spend a lot of time on in it, but many times people don’t understand whatis available. i told a brief story to sylvia just a minute ago about, i presentedat a conference in portland, oregon, and i was asked to speak about medicationand how people can get their medications funded. of course from massachusetts,i said "well, that's not really a problem because meds are covered under ourhealth care." i did all this abundant

research and i presented this little programand people in the audience, from portland, were so grateful because theyhad no idea that some of these things were available. we live in this world of perpetualmotion and sometimes we don't stop to see what is right in front of us. helping families to see what is availableand understanding how to access that and utilize it without fear of repercussion. a lot of motivational interviewing, so muchso that the supervisors have been encouraged not only to attend motivationalinterviewing trainings, but also to utilize motivational interviewing with theircommunity health workers.

does everybody have a sense of what motivationalinterviewing is? raise your hand if you've heard of motivationalinterviewing. okay, it's the idea that you are not goingin there and saying, “i think you should do this, i think should do that.” it's more,you know, "how are things going? can you tell me about your child's asthma?" andthen, if the family says, “well, he is waking me up four nights out of the week.”"that sounds tough. it doesn’t sound like he's having good nights.” reflectingback what they say and then initiating a conversation whereby you say, “what aresome things do you think we could do to help resolve this situation?” you arepulling them into the conversation as part

of the solution and not going there – youknow i have been a nurse since 1976 and the old model for me was, "go in. youare the patient, i’m the nurse. i know what you need. here’s the list, do it andyou will get better." that's how we all operated and i think part of that is the wisdomof aging, but also recognizing that that does not work. doesn’t work whetheryou are doing it with your kids, or whether you are doing it with your patients.people have to feel “part of” in order to embrace what you are trying to sharewith them. motivational interviewing is huge. as far as community health workers being preparedfor emergencies in the home,

i will give you a little scenario and i thinkwe are probably a little bit ahead of time, but you know what, look at just the casestudy with david. david was a young boy. i think he was 12 or 13 and he was on school vacation thispast february and our haitian community health worker went to visit david and hisfamily. david was haitian. david was really sick. i happened to be onan observation visit that particular day and it was clear to me when we walked in thathe needed a couple puffs of his inhaler. we encouraged him to just take – he wasn’tfeeling well, we established that. we encouraged him to take some albuterol,and without giving the story away,

his mom was very upset with david, and kathleenasked him several questions which are part of the protocol, and we uncoveredthat david had been telling his mother that he had been taking his medication whenin fact he hadn’t. this little scenario is something that weuse for the training for the community health workers and i’ll pose that question to you.you come into a home. the child is really sick. you certainly want to treat thechild. mom is really upset because david told this lie about the medication and howhe had been taking it, when he really hadn't been. mom lays it to david and is very,very upset with him, shaming him, just making him really kind of hang his headlow. as the community health worker,

what do you suppose is the most importantissue there - was there to address? the relationship. anybody else? do we all agree it was the relationship? i think what happened was his older sisterwas there and his mom was there and they just literally, i've never seen anybodyyell at somebody in front of, you know, people from outside. they were really upset.and i learned from kathleen that in the haitian culture, lying is like - youdon’t lie. you do not lie. that is wrong. so kathleen needed to finesse the situationand explain to mom that, could she see that david was struggling to breath? try toturn her from, yes, i understand that,

however david is really sick. perhaps he ... the ultimate excuse was that he lost his medicationand that is why he hadn’t taken it. so mom got angry that, why didn’t you tellme? but when he tried to speak to mom, mom was very authoritarian and you know, justnot interested in talking with him. kathleen tried to make her see that that’simportant. your child shouldn’t lie to you, however, do you recognize that he is sick?his sister was there and his mom was there and neither of them really recognizedhow sick he actually was. long story short, we worked through that and spent agreat deal of the visit talking about recognizing symptoms. you know, he was dragging,he was having shortness of

breath, you could hear him wheeze. sometimes parents have to be in partnership,especially with older kids, because parents tend to take responsibility when thechild is young, but when they get older it's like, it is their responsibility. and i thinkguidance, sometimes when you are not feeling sick, you don’t always do what’sright. kathleen spent a lot of time with mom, a lot of time with the older sister anda lot of time with david helping him to understand that by being proactive andhonest with his mom, number one he was going to feel better because he’d gethis medication sooner, and it would help him in that he was approaching his mom sothen he would have support of

his mother as well. during that visit we did a couple of things.he didn’t have his controller medication. he had a nebulizer that didn’t work andhe had albuterol. it was a friday afternoon and we actually set him up with an appointmentfor the company to come and replace the nebulizer. we called the clinic. in this case, i called the clinic. but hadi not been at the visit, kathleen would have called me and i would have transmitted that informationto the clinic. what i usually do is call the triage nurse and then the triage nursetakes care of whatever is necessary. i think, in terms of assessment skills, certainly,they do not have the level of

assessment that a licensed, registered nursewould with advanced degrees, et cetera, but i think part of the training is recognizingthat and if you can transfer that training into the home, you can tell when someone isnot breathing well. what is important is to know what to do with that informationand that - going back to the asthma action plan - that is a good tool for theasthma action plan, to be utilized when somebody thinks, “i’m not sure whatto do but i am going to go here and i’m going to do it." the community health workerknows what they can do within the home and knows when to access support on the outside. in terms of the supervisor training, it isa two-day training.

again, we encourage people to go through thecommunity health worker training, so that they understand what their communityhealth workers are doing. we look at the scope of practice and talkto community health workers about how you don't alter anything on an asthmaaction plan, you don’t make recommendations about changing medicationsor anything like that. as i said, the supervisors go through motivationalinterviewing and are encouraged to use it with their communityhealth workers so that it's kind of a role model, role play. they go through asthma basics. we’ve talkeda lot about the different types of

supervision and it is important that whoeveris supervising a community health worker understands asthma so that they canpick up on those key messages when something isn’t going well. supervisorsare also, especially in a clinic based setting, it's important for community health workersto have an assigned role - and in your packet there is a job description - that thesupervisors not only help to integrate them into the health care team, but also toprevent them from being the go-to person, "would you do this for me and wouldyou do that for me?" they have a defined role and they need tostay within that role. they also go out for observation visits forquality assurance and we have

supervisory support calls, sharing ideas,sometimes we even share patients because someone may not fit our model so wewill refer a patient off. i already did that. megan is going to talk a little about howyou integrate them into various settings. megan: i sometimes will talk about the keysto success for community health workers are the “c” then the “s” then the “i”,right? the c is certification, so making sure that community health workers have been trained,being able to make sure that they meet certain competencies and other things.the s is supervision, right? these community health workers do not practice solo,that they are well supervised.

that the supervision goes through training.that they are able to think about what their role is within a team, so thatreally community health workers don’t practice solo, that they’re members of ateam. then the last one is this idea of integration. i think that more and more thereare lot of different ways – behavioral health integration is somethingthat people are talking about. how do you integrate into primary care or into home basedservices? in many ways, i think there are a lot of different ways that communityhealth workers can be integrated. one of them is in the medical home in thedelivery of care where they’re a recognized kind of trusted member of the team. this iswhere it is really important that even if

the community health worker is predominantlydoing home based services, i still think they need to check-in in the medicalhome. for instance we started at boston medical center, but expanded to one of thelargest community health centers in boston, called east boston neighborhood healthcenter. we actually brought over both community health workers to meet keyclinical staff so that when clinical staff talk about, “oh i am going to refer youto benita”, they've met benita, they know who benita is. they've met kathleen, theyknow who kathleen is. it is very clear to them who is which community health workerand that they're able to feel confident that they are part of the east boston team.

we are currently in the third year of thegrant from the center for medicare and medicaid that funded that expansion. the communityhealth center is already talking about how are they going to continue thisprogram after funding because they feel like they do not want to go back. they now haveseen what it is like to be able to have this available as part of their resource,and they want to think about it as if the person would become an east boston neighborhoodhealth center employee. they want to think about how they are going to be ableto do that. but a medical home is not the only place that they necessarily could beintegrated. i think public health departments can employ community health workers.that's one of the models we

have in boston to fill some of the gaps aroundlanguage access. i think that in many ways, when you think about it, you may havefive or six languages that you need. you need somali, hmong, you are going to needspanish, you are going to need other ones, so that it is going to be hard for youto employ enough people, so you could think of where a public health departmentcan become a base for a one-stop shopping for contacts, where you are ableto say, “okay. we are going to be able to pool resources so that we can have the linguisticand cultural capabilities and be able to do that.” the other benefit of being integrated at apublic health department is that you are

integrated with other services. you are integratedwith inspectional services, and code enforcement that the boards of healthtypically do. you may be integrated with public benefits and other programs. we'vehad really nice partnerships around particularly younger kids that may have healthystart nurses going into the homes for after babies are born and things likethat, and having the community health worker who's been specially trained with theenvironmental stuff and other things do joint visits together and being able topotentially even prevent some of the wheezing because you are able to prevent thetriggers earlier and save a child’s life. the last piece of integration is that i feellike especially as many medical homes are

going to electronic health records, is thatit's really important to view this as part of care. one of the things that i think isreally important is not just to have either a mailed copy of what happened or a faxed copy,but to actually put a note in the electronic record so that a clinician cansee that this happened, what happened at the visit, so that they recognize that thisservice is going on. i think sometimes if it's partnering with a social service agency whereyou don’t get that feedback loop, you can understand why someone wouldn’tutilize the program because you don’t know what is happening with it. i didn’t put on this "integration" - integratinginto the school environment. we think

about where kids of school age spend the mosttime. they often spend the most time at school, so thinking about ways inwhich to integrate, not only for the parents so that the parent knows what is going on,but then also integrating back to the clinical environment and making that a seamlesstransition. and there sometimes are some barriers around hipaa, about being ableto share information, but those are overcomeable. those are models that can bedone, that can be really important. anne: if the community health worker wentin the home and first of all found that the child’s technique with a discus,say, wasn’t good, they would contact me and say, “you know, perhaps he is not feelingwell because he is not getting his medicine.

he does not know how to use this thing.”then i will call the triage nurse or i will contact the physician and say we had a home visitand this is what happened and i am leaving it in your hands to make a decision as towhat you want to do. let me know and then we will go back and reteach. kids will bediagnosed with asthma and they'll be sent home with abuterol. when i scan the medicalrecord, i see that the child's had three, sometimes four, burst of steroids ina year and i kinda go like that. then when the community health worker comesback with documentation, they really know "controller, controller. rescue. controller." they are taught to know that asthmatics shouldon controllers,

so they’ll usually point that out to me,i’ll also see it in the redcap data, because there's a list of medications, howfrequently they're supposed to be taken and how frequently they actually are taken. if there's a disconnect, i will usually checkwith the community health worker that it wasn't just an error. i will often say "canyou call mom and just clarify are they taking this or are they not? do they really not havea controller?” so i have my data aligned, my ducks in a row. and then i'll call the physician and i'llsay "okay. i had the community health worker double check with the family. this is whatmom reports. i see in the medical record

that you’ve ordered this and there was nosign of that. perhaps they were on it at one point, they ran out and didn’t refill it."and then i go back to the community healthy worker, “can you call mom again and askher, or can you schedule that second visit a little earlier?” and check in to reallyestablish what is really happening. sometimes we find people who - they run outof flovent and they have some med that the child was on two years ago, and theywill pull that out of the drawer and start using it. there is a lot - again, being theeyes in the home can tell you so much. ultimately what they see, if there's a disconnectthere, they report it to me. i make the judgment as to whether or not - ilook at the medical record to see what

the actual orders are and make sure that iswhat's being followed in the home. megan: i think what's key is the communityhealth worker and really anne don’t make a clinical treatment decision. they bringit back to the treating physician and say, “here is some information. like in the lastnote it said you went up for flovent 220, but so you know, the patient is reportingto us they are still using 110. what do you want us to do? do you want us to tell themto get the 220, and start using it?” or, “they seem to be doing pretty well on the110, what do you want?” the other piece we uncover a lot is they havenot just one asthma action plan, they have three asthma action plans. the havean asthma action plan they got from

the er, they have the asthma action plan theygot from their specialist, and they have the asthma action plan they got from theirprimary care doctor, and they're not the same. they are all different. we willgo back to, frankly, the doctor – and this is where it sometimes gets difficult.which doctor do we go back to? so we tend to say the er doctor gets the least- because they were not part of the continuity team, so then we’ll go to theasthma specialist and the primary care and say, which one is the right one? tell us which you want us to be teaching,right? i really want to emphasize that it’s reallyinformation gathering, not clinical decision

making. this is why i really emphasize theintegration piece, is that the only way you know that is if somebody at anne’s levelhas access to the medical record and can look and see what's reported to be what'ssupposed to be going on. then the eyes and ears of this community healthworker report back what actually is going on. there are definitely times whenpatients will actually do what you ask which is bringing your medicines from home.that is – we almost put in a slide. so robin gave usliterally the most beautiful slide which was like, twenty inhalers. twenty differentinhalers of five different flovents, some advairs, some albuterols, proair, and non-hfaand hfa and literally –

they have the baggie of stuff and nobody knowskind of what’s new and what’s not. the community health worker sometimes willbe like, “ok, this is expired.” or if it doesn’t have a counter, they maystill be puffing and have no medicine in it so we got to get rid of that. so just trying, again, not to make decisions,but just be able to implement the plan that you made in the office in a much moreeffective way. anne: when we first started this, there wasa question to whether or not the community health workers themselves woulddocument in the record, and it was decided that that would not be the case, andi'm actually happy about that because

it gives me a higher level of review of whatthey're writing, and understanding what's going on. i do a couple of things. at bostonmedical center, i free-text about a visit and i am pretty precise. at the neighborhoodhealth clinics, three of which we have patients enrolled from, i use a template,so it's pretty straight forward. i can free-text into the template if i want to addsomething. i will also add there that “patient was taking wrong medication. ichecked with physician and this is the plan” or whatever. it's basically the visit number,visit one or visit four, it's the date, it's whether the child - they do the asthma controltest at every visit, so that is included there. after i do that, is the childwell controlled, not controlled? and then

there is a drop down menu where if i say thechild is not well controlled it will say, “what was the advice given? did you callthe clinic while you were at the visit? did you suggest two days of albuterol and havethe family call the clinic to schedule a follow-up appointment? did you call the emergencyroom?” there is a whole drop down menu. there is a drop down menu for environmentaltriggers, for the products that we bring in, what was delivered,so that the nurse practitioner in the clinic will ask the family, “areyou using the vacuum cleaner and how do you like the fact that you have natural cleaning products? is that working for you?” so again, there's this incredible connection, andas i said, there is an opportunity to

free-text whenever i want. megan: i think i can’t emphasize enoughthat two-way communication and that someone at the appropriate licensing levelis putting the information in. for me, i think our community health workersare actually amazing, but i wouldn’t want to put that burden on them. i think itis better for anne in her supervision will review what is written from the redcaps.we are trying to make the seamless communication real time. we are able to seewhat time the information is entered into red cap. we are able to do that, andthen be able to translate that into the electronic record. sometimes if there is amore urgent thing, like what controller do

you want them on? she can either flag thephysician using the electronic record and then make the change, or if it is more emergent,page the physician or call the nurse for the clinic. janelle in the back and then... audience member: on the family, the haitianfamily, into look at as far as support groups for the family goes... megan: the question was really related aroundsupport systems for the family itself and not just thinking about the individual,but thinking about the family, whether it be support groups, or connected to faith basedorganizations, or other things. i would say absolutely. we have actually started lookinginto would you look into,

"could you do a case rate that is family basedinstead of individually based?” so you sometimes will have parents and kidsthat have different forms of insurance, right? one will have one medicaidmanaged care and another one will have a different one and maybe there is athird one, and that can make it more difficult. but if you did a line where youhad - everyone had neighborhood health plan, you could imagine. because that would actuallythen - potentially be able to spend more time in the home, be able to treat everyone’sasthma, because we know that this can be familial, where oftentimes youhave a parent with asthma and a child with asthma, and be able to do it.

it's tricky because trying to think through- with that complexity, not everyone goes to the same health home, so you can imaginehaving to communicate with multiple health homes for it. i totally agree withyou. i think that in many ways, when we think about this intervention, we shouldn’tjust think about it on the individual level, we should think better on the family level. the other thing that is really interestingis starting to think about community health workers in a more community level, right?so the idea that there is a lot of evidence now about the interplay between individualhealth and community health. one of the things that our community healthworkers spend a lot of time on is frankly

legal issues, housing code enforcement orother things. they've been trained by legal aid attorneys and things like that,and there's more evidence around – this was work that was done in cincinnatiaround the idea of, you can spot kind of individual landlords that aren’tdoing what they are supposed to be doing and then you can track those landlords andthen potentially force the landlords to make the buildings better. the flipside is you can actually track communitiesand look at what's the density of code violations in that community. can youactually see a heat map around the concentrated areas where there are more codeviolations and then look at whether

individuals are more likely to end up in theemergency room based not on your home but the homes around you? andy beck is the first author on those papers.one was published in pediatrics, one was published in health affairs. i think you'reright. what we are describing, in some ways, is avery simplistic, unilateral view of how a community health worker could be viewed. weare describing an intense model. again, not every asthmatic is going to needit. but i think it starts to speak more towards thinking on the more population level.and community health workers - there have been examples where community healthworkers are doing more

community health, particularly out of communityhealth centers, using that platform as a way to not only promote for the individualpatient they're seeing, but for an entire community as well. janelle, you have a ... audience member: yes, i am just wonderingabout the medication technique. have you asked the family, “show me how you use that medication?” megan: one of the nice things is neighborhoodhealth plan in massachusetts did ten different languages of visual pictorialsof how to use asthma medication. these are wonderful and they're availableon the web, you don’t need to be

from massachusetts or anything like that,so i really encourage people. they’re really helpful in terms of tryingto do techniques, but i do think that - again, the community health worker would onlydo a small piece of that. that would be something that a more medicalprofessional would follow up with and or bring them back to the clinic to beable to do it more intensively. i am going to keep going because i want tomake sure we have time for our breakout. one of the frequently asked questions we geta lot is "will community health workers replace public health nurses?" andthe answer to that is no. you couldn’t replace a public health nurse. i think ina lot ways, i tend to think of them as

public health nurse extenders. i described the heart model, the home asthma response where they have the health nurseand the community health worker do the first visit together and then have thecommunity health worker do the follow-up visits. i definitely want to make sure thatno one walks away today with the impression that we think community health workers canreplace public health nurses. can i trust what community health workersdo in the field? i think supervision in the field is important.not for every single visit, but for sporadic quality assurance purposes. going out even5% or 10% of the time just to see how things are going works for both levels. worksfor not only helping the community

health worker with their competencies, butfeels that it is important. we can tell real time from when someone uploads the data, sowe know what time the visit happened because they uploaded data from that, butthen there have been times when there have been questions about what a community healthworker is doing and that is when we can really utilize the same things that anyonewould around home visiting and other things. we talked about handling emergencies. i thinksafety is a big thing. we actually modified our protocols aroundthe first visit - now is done in pairs where a community health worker does not go outby themselves. two community health

workers or a community health worker and anobserver go out because then the family can be assessed for how safe it is for thecommunity health worker to be there by themselves. i really have emphasized to mycommunity health workers that at any point they don’t feel safe, they shouldleave. we have code phrases that they have been taughtaround how do they leave a situation that they don’t feel safe in.i think that is used in any home visiting, whether you are a public health nurse or other things, those are important things and we really emphasize those. and then clinical emergencies. how do youcall 911? how do you get someone into

a clinic? or other things, and being able toreinforce that. we do have anne as a backup anytime they are in a home and theyhave a question they can reach her by cell. i want to go over a breakout sessionthat we tried to think about. in your packets you’ve got a who, what,where, when, why and how kind of sheet. what we are hoping is that over the next 15minutes or so people will take some time to kind of start to think about who wouldbe a patient population that you would want to target if you were thinking about addinga community health worker to your healthcare asthma care team? what would bethe type of intervention you would envision a community health worker doing,right?

when and where would they deliver the service or the intervention? why would you do it?what goal would you set? what's your goal in doing it? and then startthinking how you would move forward with it. when we convene back, people can share someof their different things, and anne and i will be walking around to seeif we can help you. joan can talk about some of the alliance’sfunding for pilot grants to be able to use a toolkit to try to move this forward. sothis is meant as an exercise to help you get those juices flowing and try and think aboutit.

we’ll do this for about fifteen minutesand then wrap up. anne: i just want to quickly give you thewebsite for this because i don’t think it is – i don’t think it is included in your packet.the website is neighborhood health plan and it is www.nhp.org. and ... you click onproviders and then, a little box comes up on the right hand side of the screen and says"clinical resources" and i think it's the fourth or the fifth topic. it says “asthmaresources for education.” you click on that and you will have a choice of a number of differenthandouts. we pass out colored copies so that familiescan use them and the community health workers use them in their teaching.

megan: so i just want to walk throughthe who, what, where, when, why, and how. and if people are willing to sharesome of the stuff that they were thinking. i think the first is kind of who? who wouldbe patients that you may want to target with adding a community health worker as partof your asthma care team? audience member: the schools and obviouslythe poorly controlled students. obviously we’re going to look at ethnicity. megan: yeah, absolutely. so you’re goingto look at uncontrolled asthma and whether or not that is hospitalizations or er visitsor whether or not it's just by symptom reports, you want to able to target the highestrisk people.

absolutely. what else? audience member: [inaudible] megan: yeah, age is a huge disparity. we talka lot about disparity by racial and ethnic lines but in asthma, age is actuallyhuge. we talked about how in boston we’ve targeted the zero to four population becausethey are largely sometimes out of care in their home and they can have huge asthmadisparities around it, so certainly age targeting is another way to think about it. the thing we’ve kind of danced around, andi want to kind of talk about it head on, is the cost differential. a community healthworker doesn’t cost as much as a public

health nurse, and so i don’t want to sayreplacement but when we think about time, a community health worker can spend more timewith a family sometimes and that i think it is a huge thing. if you have someonethat has cognitive barriers. for instance, in some of our families, anasthma action plan as it traditionally is laid out, doesn’t work. we literally have donelow literacy asthma action plans with like, a sun, and a picture of the inhaler, and thenumber two. then literally a moon and a picture of the inhaler and a two. you'llliterally kind of walk through what an asthma action plan green zone lookslike with the family, to be able to do that, and i think that’s something our communityhealth workers asked for, and we were

able to help develop it with them. all right, so the “who” - you guys havea lot of good identifications of the who. so the “what.” what types of interventionswould you want a community health worker to be helping with? audience member: a healthy home assessment. megan: yeah. being able to be your eyes inthe home, walk through. be trained to identify environmental triggersthat families may not be willing to report to you, but are pretty evident whenyou are walking through the house itself. audience member: in combination with a healthyhome specialist.

megan: i was just about to say. and this iswhere an inspector could be doing the more rigorous assessment and the communityhealth worker may be the one to help with the education component. a culturally,linguistically appropriate follow up education. because a lot of the healthy housingstuff is structural but a lot of it is behavioral, right? what do you do with yourdishes, what do you do with your food preparation and where do you store the food?where do you store the garbage? are there ways we can get rid of the clutteror other things? so yeah, being able to think of that educationalfollow up is great. what other ideas?

no asthma education? i will say i forgot. anne did bring an example.we do our asthma education using a validated asthma education tool called “you can controlyour asthma.” and that was developed by the asthma and allergy foundation of america.we actually translated it to haitian creole because we felt that wasa gap, so it is available in english, spanish, and haitian creole. it has a kid booklet andan adult booklet. very low literacy and really nice, but i think that could be important. this is what it looks like and we can haveit in the front for people who want to look at it. all right, the when and where. when andwhere would you want to be able to think

about adding the community health worker? audience member: at the neighborhoods, letthem come to the neighborhood, sort of like a moving clinic. megan: there definitely are really nice models.there is one developed in l. a. with a mobile van going around to particularlyincrease access. i do think that... audience member: an environmental team. megan: i was going to say. so that's whati think is hard. i am going to argue i think a home-based component is really effective. that’s what the research kind of shows,is that –

but if you can get into the home – and that’sa big if, so i want to say - but i think that’s where we think of community healthworkers as being potentially a specialized workforce, one that could get in the homebetter because of their cultural background, their linguistic background. i think thatsometimes being able to talk as from having a physician say, “i think thisis a good idea, i am going to have the program contact you,tell you more about it,” has been something we have found effective. cold calling families doesn’t always workas well as if we have a physician endorsement, and then thinking about that.

thinking, again, about the targeting of whoyou want to reach out to, that high risk pool. they’ve already come to the er andhospital. it was a kind of a seminal event for the family. can we think about ways tofollow up with them? anne made a good point. one way we can getinto the home is the incentives. at the first visit you get the mattress covers,at the second visit you get the pest kit with the home cleaning supplies, at the thirdvisit you get the vacuum cleaner. it is not that we don’t think that the vacuumcleaner should be there at the first visit, we just delay it so that it helps us get intothe homes. being able to think through ways to use incentives, not only for yourintervention, but also to get into the home

itself. as anne alluded to, the incentivesmatch the intervention, right? we are telling them about food storage and then we give themthree tupperware containers, large tupperware containers, where they can put cereal or riceor other types of dry goods that they want to store or things like that.and then we do include... partly we have because it's a research study,we're able to get a grocery card as a final incentive to complete the program. one of the things that we have been strugglingwith is sustainability with medicaid. being able to get those as reimbursable, durablemedical goods. i probably jumped pam’s question that shewas thinking, but it is this idea of...

and i think we will get there. it will probablybe part of a bundled - sorry, a case rate where you’ll be able to figure it out. wehave been able to figure out how do we order these things from boston medical center, andfigure out the storage of them, but it's an interesting kind of sustainabilitything, because i think the services are important, but i think the goods are as importantto supplement the service in the long run. lastly, why would you do it? whatmetrics would you do or what are ways in which we would think about - what wouldyou be tracking to change? yeah. audience member: does the juniper qualityof life scale have any kind of

metrics for asthma self-advocacy management? megan: yeah. so it’s a good question. thejuniper scale does not include an efficacy scale within it. some of the studies – we decided our questionnaire was too long,so we did not do an efficacy scale. that being said, some other asthma communityhealth workers studies have, and have shown improvements in efficacyscores. in fact, i think the yes we can program, when they published it,did include an efficacy score as something they improved. i will say this. so we ask two questions aroundasthma action plans.

we ask, “do you have one?” and about 60%of the time someone yes to that at our baseline. and then we ask, “do you useit?” and so the “do you use it” question, youdrop off about twenty to thirty points. one of the things we are proud of is thatby the end of our study at least 80% of the people we say are using the asthma actionplan as their game plan every day. “what am i going to do today? am i goingto use the green zone because my kid looks pretty good? am i going to use the yellowzone, my kid is starting the get sick? and then – my kid doesn’t look good, ineed to go to the hospital.” and what’s really great is – we know we’resuccessful when the community health

worker comes back and says, “you know what?they told me the kid had a cold. and he started wheezing more, and they usedthe asthma action plan, and they didn’t have to go to the clinic, and thekid’s better now.” right? so they used it the way it’s supposed to be used. and so, ido think that this is – it’s hard in an office setting to have enoughtime to get someone to that point. and that’s why, again, i think of the communityhealth worker as an extension of me and my practice. i come up with the asthmaaction plan, i typically negotiate it with the family, but then i need someone tohelp them implement it.

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