Community Coalitions: Seattle, WA

King County Asthma Forum (KCAF)

Bridging the Gap with Community Health Workers

Founded in 1998 by the American Lung Association of Washington and the Seattle public health department, the King County Asthma Forum focuses on the diagnosis, prevention and management of asthma in Central and South Seattle and Southwest King County. Recognizing a need to expand the continuum of asthma care beyond the traditional medical setting and into the communities and homes of families suffering from asthma, KCAF implemented the community health workers (CHW) program in 2002.

The CHW program offers community and in-home asthma education and clinical care. CHWs work in communities with ethnically diverse populations, hardest hit by asthma and with the fewest resources. Most workers are from the communities they serve and are bilingual in English and the language spoken by their clients, making them especially sensitive to the issues these families struggle with daily. Trained to educate clients about self-management and help coordinate care, workers meet with families in their homes.

“Clinical settings necessarily focus on acute care and medical interventions but cannot help a family after they leave the office,” says project director James Krieger, M.D., of Public Health—Seattle and King County. “CHWs bridge the gap between the physician’s office and a family’s home, especially in the most stressed communities, where many of our families face huge language and cultural barriers and lack financial resources to seek additional care or support.”

Clients learn about CHWs from any number of outlets, such as health clinics and school nurses. Low-income families with children suffering from persistent asthma of any severity level are eligible; the program will adjust services rather than exclude a family because of income level. Three health workers carry an average caseload of 30 to 50 families at a time.

Says Carmen Olvera, a South Seattle-based CHW, “We try never to turn away those whose incomes are above the cut-off. We’ll do what we can to work with them at some capacity.”

The relationship between workers and families begins with an initial intake session to determine eligibility. A worker then visits the family’s home to review medication use and learn more about the family’s current asthma management practices. During these initial meetings, many workers find families are dealing with issues that take precedence over asthma—unemployment, homelessness and lack of food—and provide resources to help the family stabilize.

Next, CHWs conduct an environmental assessment of the family’s home, looking for common asthma triggers and teaching the family how to reduce them. Each family receives supplies, including a vacuum cleaner, non-toxic cleaning products and hypoallergenic pillows and mattress covers, to maintain a healthier home environment. Because most of the families live in substandard low-income housing, CHWs often help push landlords to improve living conditions, frequently writing letters on the family’s behalf.

CHWs continue to work with families for up to a year, visiting them at home several more times, helping them develop self-management skills, coordinating their clinical care, accompanying them to clinic appointments, and serving as their ally against asthma in clinical and school settings. Over time the workers build a strong sense of trust among clients and become an advocate for families by facilitating communication with schools, child-care providers and physicians.

Trusted Care

Carmen Olvera, a community health worker (CHW) since 2001, learned very early on the impact a CHW can have on a family’s life and health. One of her first clients was a Spanish-speaking family in South Seattle, a low-income community with high asthma rates. The family’s young son suffered from acute severe asthma. During Olvera’s initial home visit, the child experienced a severe asthma attack, and the family rushed to the doctor. Olvera went with them.

On an earlier visit to the same clinic, the doctor had diagnosed the child’s asthma and reviewed asthma medication purposes and procedures with the family. A translation mistake resulted in the misunderstanding of critical directions and the family confusing a controller for a rescue medication. Cultural norms kept the family from questioning the doctor’s instructions. They then confused medications at home, resulting in the potentially fatal attack.

During this subsequent emergency visit, Olvera, who speaks Spanish and used to live in South Seattle, was able to help the family communicate with the doctor and clarify the directions.

“This case always illustrates to me that language and cultural barriers can cost lives,” she says. “I’ve seen situations like this occur over and over again. By working together—family, doctor and myself—we were able to establish a better communication and overcome a small, but potentially deadly, misunderstanding.”

While Olvera frequently accompanies families on clinic visits, she does most of her work with them at home, where she educates them about self-management and controlling environmental triggers. She also helps them deal with larger issues that keep families from addressing asthma.

“Our families are often overwhelmed by the diagnosis of a ‘chronic disease,’” she says, “while at the same time dealing with big issues like unemployment and homelessness. Managing asthma becomes another overwhelming stressor secondary to day-to-day issues.”

In her five years on the job, Olvera, whose background is in social services, has provided resources to assist families in finding housing, employment and other services. Her familiarity with the community and knowledge of Spanish makes her a trusted support for her clients. They communicate with her in ways they might not a doctor or clinic worker, which helps her better educate them and coordinate their care among clinics, schools and child-care centers.

“Because we go into families’ homes, they open up to us,” Olvera explains. “It takes time, but they see that we want to help; that we understand where they’re coming from. With their trust in us, we are able to build on the care they receive in clinics, make sure they receive the services they need and help them be healthier at home.


Summary

KCAF is comprised of community residents, clinics and hospitals, child-care centers and schools, public health agencies and other organizations, including: the American Academy of Pediatrics—Washington Chapter; American Lung Association of Washington; Asthma Outreach Project at Odessa Brown Children’s Clinic; Community Coalition for Environmental Justice; Environmental Protection Agency; League of Women Voters; Seattle Housing Authority; Seattle University School of Nursing; Washington State Department of Health; and Washington State Medicaid.

Strategies and Programs

  • Community Health Workers (CHW); Asthma Care Training; home environmental assessments; Neighborhood Asthma Committees; community outreach through Web site, meetings with community organizations and community events
  • A Learning Collaborative that educated providers on the implementation of asthma guidelines through additional training and guideline dissemination
  • Outreach in child-care settings, including: Team Asthma Goes to School; “Chicken Soup,” a play about asthma; school asthma policies; training child-care providers; environmental assessment
  • Cross Project Coordination group; Asthma Management Coordinator; Asthma Phone Triage Line; Attack Asthma Bill
  • Current activities include CHWs, school policies (access to medications, use of action plans), another learning collaborative and state-level asthma policy efforts

Children and Families Served

  • KCAF targets low-income children in Central and South Seattle and Southwest King County, where the hospitalization rate among children with asthma is almost double the King County rate as a whole and where asthma hospitalizations have increased 62 percent from 1988 to 1995.
  • 53.3 percent of the target areas’ residents are racial minorities representing more than 25 distinct ethnic groups.
hospitalizations map



Click Map to enlarge.

Childhood Asthma Hospitalizations by Health Planning Area. King County, Washington. 5-year Average: 1998-2002.



Results

  • Improved coordination across all levels:
    • Educated or trained 60 school nurses, 17 health educators/family support workers and 17 teachers in asthma management; and
    • Trained 699 child-care providers in asthma basics.
  • Improved clinical management: Quality of asthma care improved in a sustainable manner in three out of four participating clinics.
  • Improved self-management and control of environmental triggers among 274 clients receiving sustained and comprehensive services from three community health workers. After one year in the CHW program:
    • Asthma symptoms decreased by 60 percent or 2.4 days a week;
    • Costs for urgent care—hospital admissions, emergency department visits and unscheduled clinic visits—lowered by $201 to $334 per child over two months;
    • Visits to the emergency room declined by 64 percent;
    • Number of asthma management plans increased from 32 percent to 67 percent and the number of children using controller medications increased from 67 percent to 83 percent; and
    • Caregivers reported feeling much less stressed and worried about asthma at home.
  • Developed a CHW training curriculum and protocols.
  • Implemented a triage and referral system with community partners to help coordinate delivery of CHW services in the county.

Costs

Community Health Workers average $1,345 per client (more recent costs are $950 to $1,000 per client). This cost covers supplies, CHWs salaries and benefits, overhead, materials, administrative and supervisory support, and data management. KCAF’s Community Health Workers are currently funded by Steps to a Healthy US.

Lessons Learned

  • Be flexible. Every family is different and the program should be tailored to a family’s needs as well as a community’s needs.
  • Hire from the community. If possible, hire CHWs from the community with personal experiences with asthma.
  • Leverage resources. When possible, share resources with similar or umbrella programs.
  • Build infrastructure to support CHWs, including supervision, data systems to track clients, clerical support and accountability for productivity.
  • Clearly define the scope of work with specific protocols and accurate record keeping.
  • Establish good communication and linkages with primary medical care providers, especially in referral of patients and reporting back results of home visits.