Transcript Translating research into practice: The Asthma Counselor Model

Translating research into practice:
The Asthma Counselor Model
Pamela R. Wood, MD
Univ. Texas Health Science Center- San Antonio
March 2, 2007
Children with asthma:
obstacles affecting health
• Under-recognition/ under-treatment of
symptoms
• Confusion (prevention vs. rescue meds)
• Lack of self-management skills
• Cost of medicines and medical care
• Ongoing exposure to environmental
“triggers”
Inner City Children with Asthma:
additional issues
• Access to health care
• Financial issues: on/off insurance; paying
for medicines; etc.
• Complex family and social issues
(mental health, substance abuse,
domestic violence, stress)
• Housing issues (public housing; renters)
• Exposure to environmental “triggers”
National Cooperative Inner City Asthma
Study: psychosocial issues
(Wade S. Pediatr Pulm 1997)
•
•
•
•
High levels of asthma knowledge
Lack self-management skills (scenarios)
Multiple caretakers
Compared with normative samples:
– Higher levels Child Behavior problems
– Higher levels parental stress (BSI)
– High number of undesirable life events (8/yr)
National Cooperative Inner-City Asthma
Study (NCICAS) Intervention
•
•
•
•
Inner-city children ages 5-11
515 asthma counselor/518 controls
Asthma Counselor (social worker)
Goal: Improve asthma-related behavior of
caregiver and patient
• Tailored intervention
• No direct physician involvement
NCICAS Intervention
• 12 month intervention
• Individualized risk assessment (ARAT)
• Tailored intervention
– Empowerment of family
– Focus on: environmental, psychosocial, access to
care, adherence
• Mattress/ pillow covers provided
• Group and individual sessions
• Monthly follow-up
Adherence
•
Improve medication availability
(assistance programs)
Getting child to take medication
Adhering to medication plan
•
•
•
•
•
•
Rescue vs. controller meds
Reinforcement
Strategies for remembering medications
Issues of multiple caretakers
Environmental Issues
• Allergy testing to identify specific allergies
• Identify allergens/ irritants in home
• Strategies to reduce “triggers” at home
•
•
•
•
Mattress and pillow covers
Reduce exposure to tobacco smoke
Pets
Housing issues (mold; cockroach; etc.)
6
Symptom Days
5
4
3
2
Control
Intervention
1
0
Baseline
Sept
Mar-Apr
July-Aug
Month
J Pediatr 1999;135:332
Nov-Dec
Cost of Intervention
NCICAS - $9.20 per symptom-free day
gained (95% CI - $12.56-55.29)
Moving health interventions from
research to practice
• Translate/ adapt
• Implement
• Sustain
Inner City Asthma Intervention
Implementation Project (ICAI)
• Funded 2001 by CDC; administered by Alliance
of Community Health Plans
• 22 sites across nation
• “Translation” of NCICAS
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•
•
•
Develop program materials
Develop training curriculum
Provide centralized Asthma Counselor training
Monthly conference calls: problem-solve; reinforce
training
CARAT©
Child Asthma Risk Assessment Tool
• ARAT (Asthma Risk Assessment Tool)
• Developed for NCICAS
• Risk assessment from baseline questionnaires and
allergy testing results (CBCL, CAGE, Brief Symptom
Inventory, etc.)
• Results used to guide intervention
• CARAT (http://carat.asthmarisk.org/)
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•
•
•
37 items
Administered by Asthma Counselor
Web-based data entry resulted in risk profile
Allergy testing had to be requested/ arranged
Inner City Asthma Intervention
Implementation (ICAI)
Differences from NCICAS:
– Implementation project, not a research study
(no control group; data collection varied)
– No financial incentives
– Allergy testing results not available at
enrollment
– Asthma Counselor interviewed client to
determine asthma risk factors
Inner-City Asthma Intervention (ICAI)
Program Site Descriptions
• Asthma counselors
– 55% minority (18% AA; 41% Hispanic)
– 50% bilingual (Spanish)
• Program location
– Hospital
– Specialty clinic
– Primary care clinic
– Community health center
– Other
26%
21%
21%
16%
16%
Program site characteristics (cont)
• University-based
• Original NCICAS site
• Allergy testing on-site
– On-site; no auth. Required
55%
18%
74%
56%
Defining “Success”: Implementation
• Recruitment and enrollment
• Completion of program components
– CARAT
– Allergy testing
– “Core” intervention (group classes for adult
and child & individual family session)
• Retention
– Core + > 1 follow-up visit (“partial completion”)
– Competed all elements; 12 months program
Enrollment
• Target population:
– Inner city children
– Age 5-11 years, inclusive
– Moderate or severe persistent asthma
• Target enrollment: 220/ site
• Actual enrollment: 190/site
– 4174 children
– Range per site: 124-287
Enrollment Barriers
Barriers
% sites
Contacting families
100%
Obtaining referrals
75%
Criteria not met
80%
Administering CARAT* 50%
Rank
1.9
2.0
2.2
3.9
*Child Asthma Risk Assessment Tool
Child Health Insurance Status
(n=3013)
14%
11%
56%
Medicaid
SCHIP
Uninsured
Commercial
19%
Baseline Risk Assessment: CARAT™
• Data from 9 sites: North East (3); South (2);
Midwest (2) and West (2).
• 1772 children; Median age = 7.
• Gender: 60% male (n=1339 gender known)
• Questionnaire language:
−
−
−
−
English
Spanish
Other
Not recorded
76%
21%
<1%
10%
Warman K. Ann Allergy Asthma Immunol 2006;97:S11-S15.
Summary: CARAT™ risk domains
I.
II.
III.
IV.
V.
VI.
VII.
VIII.
IX.
Exposure to Sensitized Allergens:
Environmental Exposures:
High Parental Stress:
Poor Medical Adherence:
Pessimistic Attitudes:
Smoke Exposure:
Child’s Behavioral Concerns:
Responsibility:
Sub-optimal Medical Care:
61%
48%
39%
38%
32%
24%
23%
21%
21%
Most children (51%) had risks for morbidity
in 3 or more domains.
25
20
15
%
10
5
0
0
1
2
3
4
5
6
Domains of risk
7
8
8
7
6
5
4
3
2
1
0
Sensitized to Allergens in the Home
• Allergy testing completed: 40.2%
• At least one positive skin test:
65%
• Sensitizations: dust mite (52%); cat (36%); mold
(35%); cockroach (31%); dog (25%); rodent
(17%).
• 61% of the allergy tested children were exposed
to aeroallergens in their home to which they
were sensitized.
Sub-Optimal Medical Care- 21%
•
•
•
•
•
not given written instructions (44%)
primarily receiving asthma care in ED (28%)
not usually seeing the same doctor (25%)
difficulties taking medication at school (20%)
problems making and keeping doctor’s
appointments for the child’s asthma (16%)
Completion of program
components and
Retention of participants
BARRIERS
Barriers
Parent work schedule
Transportation problems
Scheduling groups
Obtaining space
% sites
80%
65%
60%
60%
Rank
1.6
2.0
2.7
3.3
Strategies to improve retention
•
•
•
•
Selectively enrolled patients
32%
Asked families to sign “contract” 23%
Offered incentives
100%
Offered group sessions nights
and/or weekends
85%
Program “success”:
completion of program components
• Allergy testing
• “Core” Intervention: group classes (child &
adult) and individualized family session
• Follow-up monthly family sessions
• Completion of 12 months in program
Allergy Testing
• Testing available on-site – 74%
• On-site; no authorization required – 56%
• 2014 children tested (48%)
– % tested varied by site (0-100%)
– testing on-site; no auth required – 68% tested
– Not available – 19% tested
Factors associated with higher
rates of allergy testing
Effect
Variable
Asthma Counselor (AC) Hispanic
AC speaks language of client
Located in specialty/primary care clinic
Allergy testing on site without referral
Selective enrollment
Easy to obtain written asthma plans
Flexible scheduling for groups
η2/r2 Size*
.06
.14
.34
.49
.09
.07
.16
M
L
L
L
M
M
L
Completion Status (% of enrollees)
19%
25%
No Core components
Part Core
Core complete
24%
Core + >1 followup
Complete
26%
6%
“Retention rate”= %
completed entire program or
Core + >1 follow up
Factors associated with higher
retention rates
Effect
Variable
η2/r2 Size*
Asthma counselor (AC) Hispanic
AC speaks language of client
Located in specialty/ primary care clinic
Original NCICAS site
Allergy testing on-site without referral
Easy to obtain written asthma plans
.13
.13
.29
.06
.06
.15
M
M
L
M
M
L
Predictors of success: collaboration
between physician & social worker
• Administration and recruitment
– Obtaining space and resources
– “marketing” program to physicians and community
– Setting up referral and follow-up protocols
• Ongoing education and support for AC
• Coordination of patient appointments
• Communication with referral sources
Rosen CM. Ann Allergy Asthma Immunol 2006;97:S16-19.
Comparisons: NCICAS and ICAI
Variable
NCICAS
ICAI
Program type Research study
(informed consent)
Allergy testing 100% (done at
baseline
assessment)
Clinical project
Incentives
Paid for follow-up
study calls
Not paid
Completion
rate
67% (all 12 calls)
52% (partial)
25% (all)
48% (requested
by AC; often
done off-site)
Community-based implementation
of ICAI
• Inner city children can be enrolled in the ICAI in
communities, outside the research setting.
• Retention of enrollees and completion of all
intervention components is difficult
• Factors that facilitate retention include: an
asthma counselor who is representative of the
community, site location in a clinic, access to
asthma action plans, and on-site allergy testing.
Unanswered questions
• Which program components are
essential?
– Does participation in part of the intervention
result in improved health, even if the
participant is unable to complete the entire
intervention?
– Can the intervention be tailored even further?
• Is it worth the cost?
• Who will pay the cost?
Sustainability
• How do you insure job satisfaction for the
asthma counselor?
• How do you “institutionalize” the program?
• How do you fund the program?
• (How do you fund any educational
intervention?)
The asthma counselor: job satisfaction
• Valued member of a team
• Physician/ medical director support
• Opportunity to communicate with/
collaborate with other social workers
• Job description
– Consider including some “regular” social work
responsibilities.
Sustainability
[Sadof MD. Ann Allergy. 2006;97 (1):S31-35]
• 50% (9/18) sites reported continued funding
• All sustainable sites received funding from
multiple sources:
–
–
–
–
–
–
–
Non-hospital sources
Hospital funding
Health plan funding
Fee for service
Private foundation
Community center
Government (state or federal)
7
6
2
2
1
1
2
Sustainability: characteristics of
funded programs
[Sadof MD. Ann Allergy. 2006;97 (1):S31-35]
• Collected/ presented data to potential
funders:
– Program impact on symptoms and health
services use
• Had multiple community linkages (>4)
– Hospitals, schools, community leaders,
asthma support groups and coalitions,
community centers, local physicians, etc.
Reimbursement information
• National Asthma Educator Certification
Board: http://www.naecb.org/
• CPT 2006. AMA. p.407: Education and
training for patient self-management
– face-to-face time, 30 minute increments
– 98960 (single patient)
– 98961 (2-4 patients)
– 98962 (5-8 patients)
Billing codes: education and training for
patient self-management
• Services prescribed by a physician
• Provided by qualified, nonphysician healthcare
professional
• Using standardized curriculum
• Qualifications of educator & program content
must be consistent with guidelines/standards
established or recognized by physician society,
healthcare prof. society, or other appropriate
source
Research into practice: improving health
Understand the problem (descriptive data; theory)
↓
Develop intervention (evidence-based)
↓
Test the intervention
↓
Disseminate the intervention
↓
Sustain the intervention
Acknowledgements
• Dr. Meyer Kattan, Dr. Caroline Rosen, and Ms.
Laudy Rodriguez: Mount Sinai, NY, NY
• Dr. Matt Sadof: Baystate Children’s Hospital,
Springfield, MA
• Dr. Karen Warman and Dr. Ellen Silver:
Children’s Hospital at Montefiore, Bronx, NY
• CDC (contract 200-1995-00953-0049)
• John Spiegel: Alliance of Community Health
Plans, Washington, DC
ICAI: additional resources
• Research to practice: implementation of
the inner-city asthma intervention in
community setting. Annals of Allergy,
Asthma, & Immunology, July 2006. 97(1,
Suppl 1):S1-S46.
• Tool Kit (www.achp.org)
– Select “ACHP Foundation” and then “toolkit”
• CARAT: http://carat.asthmarisk.org