Johnna S. Murphy, MPH, Boston Medical Center Eugene Barros, BA, Boston Public Health Commission Sherry Dong, MPA, Tufts Medical Center National Healthy Homes Conference Nashville, TN May 28 th, 2014 Expanding Home Visiting to Other At-Risk Populations: Asian Americans and Other Populations Not Well Connected to the Medical Home 1

2 1.Engage & leverage culturally specific neighborhood and community partnerships 2. Train inspectors 3. Early Warning System (to assist tenants in maintaining their housing) 4. Healthy Homes for Children with asthma in high risk populations (education & interventions) 5. Landlord Engagement and legal advocacy

How can asthma home visiting programs (delivered by a Community Health Worker) reach underserved populations? How do we engage families who are hard to reach, such as those not connected to a medical home or those who are linguistically isolated? How do we retain these families within a program? 3

Evaluate two models of recruitment for an asthma CHW home visiting program: Tufts Medical Center (Tufts MC) targeted Chinese through Tufts MC BPHC targeted families who might not have a medical home by recruiting through housing support programs Funded by HUD and EPA: Primary Grantee=Boston Public Health Commission, with support from Boston Medical Center and Tufts MC 4

What is a CHW? American Public Health Association:  Is a trusted member of, or deeply understands, the community served  Is a liaison between health and social services and the community  A CHW builds individual and community capacity through: Outreach Community education Informal counseling Social support Advocacy BPHC CHW Nathalie Bazil demonstrates proper use of spacer in Boston home 5

CHWs and Asthma Home Visits CHWs deliver asthma and medication education in the home CHWs offer advice and tools for reducing asthma triggers CHWs provide referrals and advocacy Studies support effectiveness of multi- component home visit interventions in improving asthma outcomes and reducing urgent care use. 6

CHW asthma home visiting programs have historically been successful in Boston Evidence supports strong clinic integration and communication between families, CHWs, and providers Challenges include recruiting and retaining hard to reach families Those not connected to a clinic or medical home Those linguistically or culturally isolated from providers 7

BPHC utilized trusted community and housing partners and integrating referral into existing systems: Breathe Easy at Home-a web based system that allows health care professionals to directly refer to inspectional services Metropolitan Boston Housing Partnership-a city wide Section 8 administrator that reaches thousands of low income tenants each year These programs referred families to BPHC for a BPHC CHW delivered home visiting intervention 8

Asian immigrants tend to underutilize health care services often lack the information necessary to practice preventive health maintenance. cultural differences and linguistic barriers, financial concerns, such as lack of health insurance. > 50% of Boston Chinatown residents are non- or limited- English proficient 9

part of The Asthma Prevention and Management Initiative launched by Tufts MC and the Floating Hospital for Children aims to improve the outcomes of children with asthma and decrease utilization of acute care services for asthma-related problems. Families were recruited through Tufts MC pediatric clinics (strong ties to the medical home) CHW and program manager was from the community and understood culture and local resources CHW fluent in Cantonese, Mandarin, and English But what about families not connected to a medical home? 10

CHWs conducted surveys and environmental assessments: environmental triggers (measured by dust, mold, pests, pets, smoking, and chemical use) Asthma Control Test -health care utilization -quick-relief and controller use -symptom days Perceived Stress Scale 11

Both Tufts MC and BPHC CHWs provided the same intervention: 3 protocol defined home visit interventions and 1 follow up phone call support and education on home maintenance (including house cleaning) pest control education and IPM services environmental tobacco smoke education Supplies (HEPA vacuum, cleaning kit, traps, allergen blocking mattress covers) connected children and families to needed medical treatment and case management 12

Number of families enrolled, completed intervention, and completed follow up by site 13

BPHC % (n=50) Tufts MC % (n=32) Combined % (n=82) Race Black Asian28133 White18312 NH/PI0 3 1 Other

BPHC% (n=50) Tufts MC% (n=32) Combined % (82) English Haitian Creole402 Spanish402 Portuguese201 Cantonese05923 Toisanese031 Mandarin0135 Vietnamese031 15

BPHC % (n=30) Tufts MC% (n=32) Combined % (n=62) Less than 8 th grade 2136 Some High School High School or GED Some College College, Grad or Post Grad

A score of 19 or less indicates not well controlled asthma 17

Percentage of Families with Asthma Action Plan by visit 18

19

Percentage of families with pests by visit 20

Percentage of families with pets by visit 21

Percentage of families with smoking allowed in home by visit 22

Percentage of families with mold by visit 23

Percentage of families with dust by visit 24

Percentage of families who use abundant chemicals by visit 25

A sum of total triggers was calculated (pests, pets, smoking, mold, dust, and chemicals). Average Trigger Scores by Visit 26

27 BPHC was successful in recruitment Fewer follow-up visits but 80% completed six month follow-up. Many BPHC participants self-referred High levels of ED and hospitalization at baseline Recruitment through housing and public health should be considered.

Tufts MC was successful in retaining families, with 76% completing intervention, as opposed to 52% of BPHC Cultural and linguistic competence Families seeing value in the APMI program Interdisciplinary APMI team Tufts MC clinic base of operations for CHWs/APMI staff 28

Both groups saw positive results Very different at baseline Reduced urgent care utilization, improved ACT scores, and lower environmental triggers Strong cultural understanding, ability to act as health care bridge Both needs targeted programs 29

Despite universal health care in Massachusetts, many of the BPHC subjects had very poor asthma control but no access to medical home. Willing to self identify How do we continue to reach these families for home visiting and connect them to clinical care? BPHC families possibly were more stressed, had worse health outcomes, etc. making keeping appointments more difficult? How do we ensure successful completion of program, once recruited? 30

HUD Demonstration Grant MALHH Environmental Protection Agency Megan Sandel, MD, MPH at Boston Medical Center Margaret Reid, RN and Nathalie Bazil at Boston Public Health Commission May Chin, RN and Brenda Situ at Tufts Medical Center 31