Community Health Worker Intervention to Address Social Determinants of Health for Children Hospitalized With Asthma

This was a pilot study conducted in partnership with the Center for Community Health Navigation (CCHN), formerly referred to as Washington Heights/Inwood Network for Asthma.¹³  This study included patients aged <21 years with a documented diagnosis of asthma who were hospitalized on a pediatric hospital medicine service during the 18-month period from October 2016 to April 2018. Patients were excluded if they did not complete an initial SDOH screening with a CHW. This study was approved by our institutional review board.

This study was set in an academic, quaternary care children’s hospital serving a predominantly Hispanic community. The 200-bed children’s hospital had 282 admissions for asthma exacerbations in 2017. The hospital is located in a community district in Northern Manhattan in New York City that is facing a significant burden of social needs: 22% of households have limited English proficiency, 35% of parents have unstable employment, and 28% of children are living in poverty.¹⁴  At the time of this study, there was no standardized inpatient workflow for SDOH screening or referral to social resources.

The CCHN is a hospital-community partnership model established in 2005 to improve the health and well-being of patients through the delivery of culturally sensitive, peer-based support in the clinical and community settings.¹⁵  The CCHN began with a program to address the burden of asthma in a community in which emergency department (ED) use for childhood asthma was nearly 4 times the national average, and it has since expanded across multiple sites in New York City.¹³  The CCHN works in partnership with local community-based organizations (CBOs) to employ and train bilingual CHWs to assess SDOH and provide customized resources, education, and community navigation support. The CHWs are jointly interviewed, trained, and supervised by both CBO and hospital staff. CHWs, who bring years of relevant, community-based experience, are trained using a standardized curriculum based on local best practices and evidence-based strategies for asthma management.^16,17  Specific areas of training include pediatric asthma education, survey administration, home environmental assessments including integrated pest management, local community knowledge, and available social resources, such as legal and housing advocacy.

During this pilot study, patients were referred to the CCHN during hospitalizations by a member of the pediatric hospital medicine team. Patients were eligible for referral if they were admitted to the children’s hospital with a diagnosis of asthma and lived in New York City. During the index hospitalization, patients and caregivers were visited in person at the bedside by bilingual CHWs, provided with peer-level asthma education, and invited to continue to participate in the CCHN CHW program after discharge. Caregivers consented to enroll in the program.

After the index hospitalization, CHWs administered an in-person interview with the patient’s caregiver during an initial home visit or in a CBO. Children and adolescents were invited to participate in this interview on the basis of developmental level. The intake interview occurred, on average, within 1 month of hospitalization. This standardized interview was developed jointly with the CBOs and included screening questions about demographics, asthma burden, and SDOH. During the intake assessment, CHWs offered community navigation support, which included referrals to targeted social resources and assistance navigating those resources when desired (eg, filling out applications with families and attending appointments with non-English speaking families). CHWs also offered asthma education and assistance with goal setting to improve asthma management.

Demographics, asthma burden, SDOH, and measures of social resource navigation were determined via retrospective chart review of the standardized CHW intake questionnaire. Demographics included sex, age, race and ethnicity, primary language, and primary insurance. Measures of asthma burden included prescriptions for asthma controller medication (proxy for asthma severity), self-reported ED visits and hospitalizations in the past year, and missed school days and caregiver workdays (for employed caregivers) due to asthma in the past year.

Measures of SDOH included caregiver education level, caregiver employment, food and housing insecurity, housing conditions, and health care access.¹⁸  Food insecurity was defined as any of the following over the past 12 months: difficulty accessing food, food not lasting until the end of the month, or concern that food would run out before the end of the month. Housing insecurity was defined as difficulty accessing housing over the past 12 months. Poor housing conditions were defined as documented pests (eg, cockroaches and rats), mold, or housing disrepair (eg, peeling paint). Poor health care access was defined as difficulty accessing medical care over the past 12 months. Social risk factors were defined as caregiver education to the level of high school or less,¹⁹  caregiver employment less than full-time,²⁰  food insecurity, housing insecurity, poor housing conditions, or poor health care access. Measures of social resource navigation included documentation of offered social resource referrals or community navigation.

Descriptive statistics were used to assess rates of demographics, asthma burden, SDOH and/or social risk factors, and social resource navigation. Missing data were excluded from analysis. All analyses were conducted by using Stata version 14.1 (Stata Corp, College Station, TX).

This study included 80 patients who underwent SDOH screen with a CHW after index hospitalization. Demographic information and asthma burden are listed in Table 1. The majority of patients were Hispanic (81.3%, n = 65). Of Hispanic patients, most identified as Dominican (70.0%, n = 45), Puerto Rican (13.8%, n = 9), or Mexican (12.3%, n = 8). Most caregivers spoke Spanish either solely or bilingually (66.3%, n = 53). Most caregivers reported multiple ED visits (62.8%, n = 49) and hospitalizations (53.9%, n = 42) for their child because of asthma in the past year. Median missed annual school days due to asthma was 7 (interquartile range [IQR] 4–14), and median missed annual caregiver workdays due to asthma was 4 (IQR 0–8).

SDOH measures are listed in Table 2. Most caregivers reported education to high school level or less (60.0%, n = 48) and were employed less than full-time (68.3%, n = 54). Half of caregivers reported either food or housing insecurity over the past 12 months (50.0%, n = 40), and most patients were living in poor housing conditions (63.8%, n = 51). Almost all patients had at least 1 social risk factor present (93.8%, n = 75), with most patients having multiple risk factors (median 3 and IQR 2–3).

CHWs helped virtually all families navigate social resources (98.8%, n = 79) (Table 3). The most commonly navigated social resources were housing resources (82.5%, n = 66), food resources (42.5%, n = 34), and medical appointments (41.3%, n = 33). Other common resources included job training (8.75%, n = 6), school and/or day care navigation (8.75%, n = 6), and caregiver English classes (7.5%, n = 6).

In this pilot study, bilingual CHWs were able to discover a high burden of unmet social needs and provide associated social resource navigation in a largely Hispanic pediatric population hospitalized for asthma. Almost all children in this cohort had documented social risk factors, including food insecurity and low caregiver education, and the majority had multiple risk factors. These rates are higher than national averages.^21,22  CHWs provided virtually all families with targeted resource navigation, such as assistance filling out applications for public housing. These findings suggest that hospital-community partnership models, with CHWs at the center of the intervention, can successfully integrate into the inpatient setting to provide social resource navigation.

CHWs in this pilot study were able to help families navigate a wide variety of social resources. Unmet social needs are associated with worse pediatric asthma outcomes,²³  and social resource navigation has been revealed to improve pediatric health outcomes and health care use.^24,25  However, nearly one-third of hospitalized children with unmet social needs are not enrolled in safety net programs for which they qualify.²⁶  SDOH are infrequently screened in the inpatient setting, with one recent multicenter survey revealing that inpatient pediatric SDOH screening is consistently performed by 29% of hospitalists and 41% of nurses.⁵  Reported barriers to SDOH screening by pediatricians include discomfort with screening, provider time constraints, and lack of knowledge about available resources.^5,27  Inpatient interventions that use nonphysician, trusted health care workers may be well suited to addressing this need.

CHW programs represent a promising solution to increase inpatient SDOH screening and resource navigation. CHWs have a unique role as both trained public health workers and members of the communities they serve.⁸  CHWs may be particularly well suited to addressing SDOH because of their health advocacy skills, cultural and language affinity, and knowledge of community resources.^9,10  A growing body of evidence has revealed that CHW programs improve asthma symptoms, decrease asthma-related health care use, and are cost-effective.^13,28–30  Although most pediatric CHW programs have been based in the outpatient or ED setting,^12,30  recent studies have suggested that hospital-community partnerships with inpatient components can improve pediatric asthma outcomes.^31–33 

CHW programs are a promising way to deliver linguistically and culturally competent care in Hispanic communities.¹¹  Hispanic patients, especially those who are foreign born, may have unique barriers to health care, including language and cultural discordance with providers, immigration-related concerns, and access to education.^11,34  In this pilot study, bilingual CHWs were able to provide resource navigation to address many of these barriers, including culturally tailored asthma education, legal assistance for immigration concerns, and caregiver enrollment in English classes, General Educational Development (GED) coursework, and job training. These findings suggest that CHWs can play a crucial role as intermediaries between Hispanic communities and the health care system, creating opportunities that may improve asthma outcomes.

This study has several limitations. First, this pilot study took place at a single site over an 18-month period, which limits its generalizability and statistical power. Second, we did not examine data by specific Hispanic subgroup because of small sample sizes. Hispanic communities are diverse and heterogeneous, and SDOH have been differentially correlated with asthma morbidity in Hispanic subgroups.³⁵  Therefore, it is critical that we examine the impact of social resource navigation in different Hispanic populations to minimize health care disparities. Finally, in this intervention, we did not compare outcomes for children enrolled in the CHW program to a control group of children, which will be critical in future work to determine long-term impact.

We found that in a hospital-community partnership involving bilingual CHWs, we were able to identify a high burden of unmet social needs in this largely Hispanic pediatric population hospitalized for asthma, as well as provide almost all families with social resource navigation. CHW programs have a high potential impact to improve asthma outcomes by linking hospitalized patients with available social resources. Interventions for hospital systems to consider on the basis of these findings include involving CBOs as key stakeholders in inpatient interventions, integrating CHW programs into the inpatient setting to provide linguistically and culturally competent care during hospitalizations, and providing targeted social resources during or shortly after hospitalizations that address the specific needs of the local community.³⁶ 

We thank the CHWs at the CCHN for their contributions.