Video Abstract
The Community Asthma Initiative (CAI) was included in the New England Asthma Innovations Collaborative, which received a Centers for Medicare and Medicaid Services (CMS) Innovation grant. Under this grant, CAI transitioned from a mixed community health worker and nurse model to a nurse-supervised community health worker model. CMS limited enrollment to patients with Medicaid and encouraged 3 home visits per family.
A total of 389 patients enrolled under the CMS grant at Boston Children’s Hospital from 2013 to 2015 (CMS group) were compared with 733 CAI patients with Medicaid enrolled from 2005 to 2012 (comparison group). Changes in 5 asthma-related measures (emergency department visits, hospitalizations, physical activity limitations, missed school days, and parent and/or guardian missed workdays) were compared between baseline and 6 and 12 months postenrollment. Measures were analyzed as dichotomous variables using logistic regression. Numbers of occurrences were analyzed as continuous variables. Changes in quality of life (QoL) among the CMS group were examined through a 13-question survey with activity and emotional health subscales.
Although patients in both groups exhibited improvement in all measures, the CMS group had greater odds of decreased hospitalizations (odds ratio 3.13 [95% confidence interval 1.49–6.59]), missed school days (1.91 [1.09–3.36]), and parent and/or guardian missed workdays (2.72 [1.15–6.41]) compared to the comparison group. Twelve months postenrollment, the CMS group experienced improvement in all QoL questions and subscales (all P values <.01).
The CMS group showed improved outcomes for hospitalizations and missed school and workdays compared to the comparison group. The CMS group also exhibited significant improvement in QoL.
Asthma is one of the most common chronic illnesses among children in the United States, and pediatric asthma rates in Massachusetts are among the highest in the country. Home-visiting programs have been shown to improve pediatric asthma–related health outcomes.
Home-visiting programs that use a nurse-supervised community health worker model are just as, if not more, effective at improving patient health outcomes. Asthma home-visiting programs have a positive impact on family members in addition to patients.
Asthma is one of the most common chronic illnesses among children in the United States, with historically higher rates among low-income Black (non-Hispanic) and Hispanic children in urban areas.1–3 The pediatric asthma rate in Massachusetts is among the highest in the country, at 12.1% among school-aged children in 2016 compared to the concurrent national average of 10.1%.1,4 Suffolk County, which includes the city of Boston, consistently has one of the largest burdens of asthma in Massachusetts, with a rate of 15.4% among school-aged children in 2016.5 The Community Asthma Initiative (CAI) is a home-visiting program located at Boston Children’s Hospital (hereafter referred to as Boston Children’s) that aims to address pediatric asthma–related racial and ethnic disparities in Boston. During the program’s planning process, we identified that 70% of patients seen in the emergency department (ED) or admitted at Boston Children’s because of asthma were from predominantly low-income Black and Hispanic Boston neighborhoods.6 In addition, pediatric asthma hospitalizations in Boston were 3 to 5 times higher among Black and Hispanic patients compared to white patients.7 Many asthma-related health outcomes are influenced by social and environmental inequities based on race and ethnicity, including poverty, food insecurity, homelessness, poor housing conditions, higher levels of air pollution, and chronic stress.8–11 However, Black and Hispanic children living in urban environments are least likely to access preventive care and receive appropriate medications for asthma control, which can increase asthma-related health outcomes and disrupt formal education, achievement, and life trajectory.12–20 To address these health disparities, CAI provides asthma case management, education, environmental assessment and remediation, and materials for families of children with asthma. Participation in home-visiting programs such as CAI has been shown to significantly improve asthma-related health outcomes after 2 to 3 home visits in 12 months.6,21–24 CAI has also demonstrated cost-effectiveness, with cost savings maintained even after patients are no longer actively participating in the program.25–27
From January 1, 2013, to December 31, 2015, CAI participated in the New England Asthma Innovations Collaborative (NEAIC), a group organized by the Asthma Regional Council of New England and supported by a Health Care Innovation Challenge Award from the Centers for Medicare and Medicaid Services (CMS). As a NEAIC member, CAI was restructured from a primarily nurse-based home-visiting model, with 1 community health worker (CHW) employed by a community-based organization (original model), to a nurse-supervised CHW model (CMS model). After the model shift, CAI patients enrolled into the CMS-supported project were limited to those with Medicaid or low income, and CHWs were encouraged to provide 3 home visits per family to standardize the program with other NEAIC sites. Patients who did not qualify under the CMS program were not included in these analyses but were still cared for by using other funds with the same standard of care. Quality of life (QoL) was assessed for all families under the CMS model by using the Pediatric Asthma Caregiver’s Quality of Life Questionnaire from Juniper et al,28 which took into account activity limitations and effects on emotional function. Under the CMS model, the nurse and the 2 CHWs were colocated at Boston Children’s, with the nurse providing clinical oversight, performing chart review, and completing in-person intakes at the hospital and the CHWs providing the vast majority of home visits. The objectives of this study were to determine the differences in asthma-related health outcomes between patients with Medicaid insurance enrolled under the previous model compared with patients enrolled under the CMS model and to analyze the changes in QoL for families enrolled under the CMS model.
Methods
Patients in the CMS intervention group were aged between 2 and 18 years, with poorly controlled asthma indicated by at least 1 asthma-related ED visit or hospitalization, or a prescription for oral corticosteroids, in the 12 months before program enrollment. Additionally, patients were Medicaid or Children’s Health Insurance Program beneficiaries; recipients of support from the Supplemental Nutrition Program for Women, Infants, and Children; or recipients of free or reduced school lunch. Patients were not eligible if they had another medical condition that affected their breathing, were already participating in an asthma intervention program, or were homeless or in state custody in a way that would interfere with the environmental assessment and remediation provided by CAI.
All CAI patients who met the criteria and were enrolled between January 1, 2013, and December 31, 2015, were included in the CMS cohort, resulting in an intervention group of 389 patients. These patients were compared with 733 patients with Medicaid insurance who were enrolled between October 1, 2005, and December 31, 2012, and were cared for under the original model (comparison group). Patients were enrolled through ED visits and hospital admission logs at Boston Children’s, as well as referrals from primary care providers. The original model included initially 1 then 2 nurses and 1 CHW located at a collaborating community agency. Under the CMS model, CAI staff consisted of 2 CHWs supervised by a nurse practitioner, all of whom were based at Boston Children’s. The CHWs in both models held bachelor’s degrees, were bicultural and multilingual, and had extensive training in asthma management, medications, home environmental assessments and remediation, and community resources through a collaboration between the Community Health Education Center and the Massachusetts Department of Public Health. This training was ongoing throughout the study period, with annual refresher courses and a learning collaborative. During both models, nurses and CHWs were encouraged to provide 3 home visits per patient. Under the CMS model, a $20 gift card was given at the third visit to further encourage families to complete a third visit.
Changes in 5 measures between the baseline intake date and the date of the 6- and 12-month follow-ups were obtained from case management data at Boston Children’s for both the CMS and comparison groups. These 5 measures were (1) number of ED visits, (2) number of hospital admissions, (3) days with limitations of physical activity, (4) number of missed school days for patients, and (5) number of missed workdays for parents and/or caregivers.
The change in QoL was measured by using the Pediatric Asthma Caregiver’s Quality of Life Questionnaire from Juniper et al28 for the CMS model group only, as part of the required data collection. The QoL measure was not collected during the comparison time period. The 13-question survey was completed by the parents of the CMS group. The responses were coded 1 through 7, with a higher score indicating a better QoL. Of these 13 questions, 4 questions assessed physical activity, and the remaining 9 questions focused on emotional health. Approval was obtained from the Boston Children’s Institutional Review Board to access hospital administrative and case management data for this program evaluation.
The demographic data for the 2 models were compared by using χ2 tests for categorical variables and the appropriate unpaired t tests for continuous variables. The outcome measures were examined as dichotomous variables on the basis of occurrence of any events and/or days (yes or no). The changes in percentage of events and/or days between baseline and 6 and 12 months for the CMS and comparison groups were analyzed by using McNamara tests. The difference in reduction in percentage of occurrence of the 5 measures between the CMS and comparison groups were then analyzed by using a test of proportions. Change from yes to no was considered improvement and was coded as 1, and no change or change from no to yes was considered no improvement and coded as 0. A logistic regression was performed with improvement as the outcome and CMS as the predictor variable (1 for the CMS group and 0 for the comparison group), controlling for number of home visits, age, sex (1 for male participants and 0 for female participants), race and/or ethnicity (Black, Hispanic, or other), language spoken (English or other), and severity of asthma (intermittent, mild persistent, moderate persistent, or severe persistent).
The 5 measures were also analyzed as continuous variables by using the number of events and/or days. The changes in number of events and/or days between baseline and 6 and 12 months for the CMS and comparison groups were calculated by using paired t tests. The difference in reduction of the number of events and/or days between the CMS and comparison groups were then analyzed by using the appropriate unpaired t tests.
Changes in QoL between baseline and 6 and 12 months for the CMS group were analyzed by using Wilcoxon signed rank tests. This measure was not collected during the original model, so these results are only available for the CMS group.
Results
A comparison of average age, sex, race and/or ethnicity, language spoken, asthma severity, and number of visits between the CMS and comparison groups are included in Table 1. The age distribution was not significantly different between the CMS and comparison groups. However, the comparison group had a higher percentage of male (P < .001), Hispanic (P < .001), and Spanish-speaking (P = .016) patients compared to the CMS group. The asthma severity also differed between the CMS and comparison groups (P = .012). On average, patients in the comparison group had 0.5 fewer home visits per patient than patients in the CMS group (1.9 vs 2.4; P = .021). CHWs performed 26.0% of the home visits in the original model compared to 90.7% of the visits in the CMS model (P = .021). The differences between the 2 groups for all variables were controlled for in the final model.
Demographic Data, Baseline Asthma Severity, and Number of Visits for the CMS Group (N = 389) and Comparison Group (N = 733)
| CMS Group | Comparison Group | P | |
|---|---|---|---|
| Age, mean (SD) | 6.7 (3.8) | 7.2 (4.4) | .06 |
| Sex, % | <.001 | ||
| Male | 57.1 | 72.6 | — |
| Female | 42.9 | 27.4 | — |
| Race or ethnicity, % | <.001 | ||
| Hispanic | 34.0 | 53.6 | — |
| Black | 53.3 | 42.2 | — |
| White | 7.1 | 1.4 | — |
| Other | 5.7 | 2.9 | — |
| Language, % | .016 | ||
| English | 77.4 | 69.3 | — |
| Spanish | 21.6 | 29.2 | — |
| Other | 1.0 | 1.5 | — |
| Severity, % | .012 | ||
| Intermittent | 4.3 | 9.3 | — |
| Mild persistent | 46.0 | 42.7 | — |
| Moderate persistent | 42.9 | 38.5 | — |
| Severe persistent | 6.7 | 9.5 | — |
| No. home visits, mean | 2.4 | 1.9 | .021 |
| Visits performed by CHW, % | 90.7 | 26.0 | — |
| CMS Group | Comparison Group | P | |
|---|---|---|---|
| Age, mean (SD) | 6.7 (3.8) | 7.2 (4.4) | .06 |
| Sex, % | <.001 | ||
| Male | 57.1 | 72.6 | — |
| Female | 42.9 | 27.4 | — |
| Race or ethnicity, % | <.001 | ||
| Hispanic | 34.0 | 53.6 | — |
| Black | 53.3 | 42.2 | — |
| White | 7.1 | 1.4 | — |
| Other | 5.7 | 2.9 | — |
| Language, % | .016 | ||
| English | 77.4 | 69.3 | — |
| Spanish | 21.6 | 29.2 | — |
| Other | 1.0 | 1.5 | — |
| Severity, % | .012 | ||
| Intermittent | 4.3 | 9.3 | — |
| Mild persistent | 46.0 | 42.7 | — |
| Moderate persistent | 42.9 | 38.5 | — |
| Severe persistent | 6.7 | 9.5 | — |
| No. home visits, mean | 2.4 | 1.9 | .021 |
| Visits performed by CHW, % | 90.7 | 26.0 | — |
P values based on unpaired t test and χ2 test. —, not applicable.
The difference in the percentage of patients who showed a decrease in each of the 5 health outcomes between the CMS and comparison groups at 6 and 12 months are included in Table 2. The following significant differences in percentage decrease for the CMS group compared to the comparison group were found: 16.8% for number of patients with any hospitalizations at 6 months (P < .001), 15.1% for number of patients with any hospitalizations at 12 months (P = .01), 33.7% for patients with any days with limitations of physical activity at 6 months (P < .001), 23.9% for days with patients with any limitations of physical activity at 12 months (P < .001), and 12.4% for number of parents and/or caregivers with any missed workdays at 6 months (P = .03).
Difference in Health Outcome Changes Between the CMS Group (N = 389) and Comparison Group (N = 733) From Baseline to 6 Months and Baseline to 12 Months
| Difference in Percentage Decrease of Patients With Any Events and/or Days (CMS Minus Comparison), % | Pa | Difference in Reduction of No. Events and/or Days (CMS Minus Comparison), n | Pb | |
|---|---|---|---|---|
| ED visits, 6 mo | −0.9 | .62 | 0 | .98 |
| ED visits, 12 mo | −4.9 | .23 | 0.03 | .42 |
| Hospital admissions, 6 mo | 16.8 | <.001 | 0.16 | .007 |
| Hospital admissions, 12 mo | 15.1 | .01 | 0.24 | <.001 |
| Limitations of physical activity, 6 mo | 33.7 | <.001 | 1.52 | .002 |
| Limitations of physical activity, 12 mo | 23.9 | <.001 | 0.38 | .25 |
| Missed school days, 6 mo | 6.6 | .16 | −0.91 | .15 |
| Missed school days, 12 mo | 9.3 | .12 | −0.76 | .31 |
| Missed workdays, 6 mo | 12.4 | .03 | −0.55 | .31 |
| Missed workdays, 12 mo | 3.5 | .23 | −0.34 | .54 |
| Difference in Percentage Decrease of Patients With Any Events and/or Days (CMS Minus Comparison), % | Pa | Difference in Reduction of No. Events and/or Days (CMS Minus Comparison), n | Pb | |
|---|---|---|---|---|
| ED visits, 6 mo | −0.9 | .62 | 0 | .98 |
| ED visits, 12 mo | −4.9 | .23 | 0.03 | .42 |
| Hospital admissions, 6 mo | 16.8 | <.001 | 0.16 | .007 |
| Hospital admissions, 12 mo | 15.1 | .01 | 0.24 | <.001 |
| Limitations of physical activity, 6 mo | 33.7 | <.001 | 1.52 | .002 |
| Limitations of physical activity, 12 mo | 23.9 | <.001 | 0.38 | .25 |
| Missed school days, 6 mo | 6.6 | .16 | −0.91 | .15 |
| Missed school days, 12 mo | 9.3 | .12 | −0.76 | .31 |
| Missed workdays, 6 mo | 12.4 | .03 | −0.55 | .31 |
| Missed workdays, 12 mo | 3.5 | .23 | −0.34 | .54 |
Difference in percentage decrease based on dichotomous variables; difference in reduction of events and/or days based on continuous variables.
P values based on test of proportions.
P values based on unpaired t test.
The changes in frequency of the 5 health outcome measures between baseline and 6 and 12 months for the CMS and comparison groups are illustrated in Fig 1 A and B. These figures demonstrate a significant decrease in all 5 measures (all P < .001) among both groups between baseline and 6 months and baseline and 12 months. Compared to the comparison group, the CMS group showed a significantly higher decrease in number of hospital admissions of 0.16 admissions at 6 months (0.65 vs 0.49 admissions; P = .007) and 0.24 admissions at 12 months (0.72 vs 0.48 admissions; P < .001) and in days with limitations in physical activity of 1.52 days at 6 months (4.06 vs 2.54 days; P = .002) (Table 2). The other 3 variables did not reveal any significant differences in the decrease between the CMS and comparison groups. After adjusting for covariates, the CMS group showed significantly higher odds of improvement in percentage of events and/or days compared to the comparison group between baseline and 12 months for the following (odds ratio [95% confidence interval]): number of hospital admissions (3.13 [1.48–6.58]), patient missed school days (1.91 [1.09–3.36]), and parent and/or caregiver missed workdays (2.71 [1.15–6.40]) (Table 3). The other variables did not reveal any significant difference in improvement between the CMS and comparison groups.
A, Change in the percentage of CMS patients (N = 389) with asthma-related outcomes (all P < .001). B, Change in the percentage of comparison patients (N = 733) with asthma-related outcomes (all P < .001). a Significant decrease for CMS patients compared to comparison patients at 12 months.
A, Change in the percentage of CMS patients (N = 389) with asthma-related outcomes (all P < .001). B, Change in the percentage of comparison patients (N = 733) with asthma-related outcomes (all P < .001). a Significant decrease for CMS patients compared to comparison patients at 12 months.
Adjusted Odds Ratio of Improvement Between Baseline and 12 Months Among the CMS Group (N = 389) and Comparison Group (N = 733)
| aOR (95% Confidence Interval) | P | |
|---|---|---|
| ED visits | 0.97 (0.54–1.73) | .923 |
| Hospital admissions | 3.13 (1.48–6.58) | .003 |
| Limitations of physical activity | 1.46 (0.86–2.48) | .16 |
| Missed school days | 1.91 (1.09–3.36) | .024 |
| Missed work days | 2.71 (1.15–6.4) | .022 |
| aOR (95% Confidence Interval) | P | |
|---|---|---|
| ED visits | 0.97 (0.54–1.73) | .923 |
| Hospital admissions | 3.13 (1.48–6.58) | .003 |
| Limitations of physical activity | 1.46 (0.86–2.48) | .16 |
| Missed school days | 1.91 (1.09–3.36) | .024 |
| Missed work days | 2.71 (1.15–6.4) | .022 |
Adjusted odds ratio (aOR) based on logistic regression analysis adjusted for baseline demographics, asthma severity, and number of home visits.
As indicated in Table 4, families of patients in the CMS group demonstrated a significant improvement in all QoL indicators except question 7 after 6 months and all indicators after 12 months. On a scale of 1 to 7, the physical activity subscale demonstrated a significant improvement by 0.96 at 6 months (P < .001) and 1.30 at 12 months (P < .001) and the emotional subscale by 0.69 at 6 months (P = .002) and 0.95 at 12 months (P < .001).
Change in QoL Scores Among CMS Patients (N = 389) Between Baseline and 6 Months and Baseline and 12 Months
| Baseline | 6 mo | 12 mo | 6 mo to Baseline | P | 12 mo to Baseline | P | |
|---|---|---|---|---|---|---|---|
| Felt helpless (question 1) | 4.35 | 4.90 | 5.40 | 0.55 | .003 | 1.05 | <.001 |
| Changed plans (question 2) | 4.47 | 5.18 | 5.65 | 0.71 | <.001 | 1.18 | <.001 |
| Felt frustrated (question 3) | 5.76 | 6.15 | 6.30 | 0.38 | .005 | 0.54 | .003 |
| Interfered with work (question 4) | 4.85 | 5.81 | 6.07 | 0.96 | <.001 | 1.21 | <.001 |
| Felt upset (question 5) | 5.24 | 6.47 | 6.57 | 1.23 | <.001 | 1.33 | <.001 |
| Did not sleep (question 6) | 3.37 | 4.70 | 4.96 | 1.33 | <.001 | 1.59 | <.001 |
| Interfered with relationships (question 7) | 6.55 | 6.51 | 7.01 | −0.04 | 0.34 | 0.46 | .004 |
| Awakened at night (question 8) | 3.62 | 4.48 | 4.85 | 0.86 | <.001 | 1.23 | <.001 |
| Felt angry about child’s asthma (question 9) | 6.09 | 6.55 | 6.66 | 0.47 | .004 | 0.57 | .003 |
| Felt angry about child’s ability (question 10) | 4.16 | 5.46 | 5.39 | 1.31 | <.001 | 1.24 | <.001 |
| Felt angry about child’s medications (question 11) | 4.55 | 5.55 | 5.74 | 1.00 | <.001 | 1.19 | <.001 |
| Felt angry about being overprotective (question 12) | 4.12 | 4.60 | 5.23 | 0.49 | .004 | 1.12 | <.001 |
| Felt angry about child’s lifestyle (question 13) | 4.58 | 5.43 | 5.66 | 0.85 | <.001 | 1.07 | <.001 |
| Physical activity subscale average (questions 2, 4, 6, and 8) | 4.08 | 5.04 | 5.38 | 0.96 | <.001 | 1.30 | <.001 |
| Emotional health subscale average (questions 1, 3, 5, 7, 9, and 13) | 5.04 | 5.73 | 6.00 | 0.69 | .002 | 0.95 | <.001 |
| Baseline | 6 mo | 12 mo | 6 mo to Baseline | P | 12 mo to Baseline | P | |
|---|---|---|---|---|---|---|---|
| Felt helpless (question 1) | 4.35 | 4.90 | 5.40 | 0.55 | .003 | 1.05 | <.001 |
| Changed plans (question 2) | 4.47 | 5.18 | 5.65 | 0.71 | <.001 | 1.18 | <.001 |
| Felt frustrated (question 3) | 5.76 | 6.15 | 6.30 | 0.38 | .005 | 0.54 | .003 |
| Interfered with work (question 4) | 4.85 | 5.81 | 6.07 | 0.96 | <.001 | 1.21 | <.001 |
| Felt upset (question 5) | 5.24 | 6.47 | 6.57 | 1.23 | <.001 | 1.33 | <.001 |
| Did not sleep (question 6) | 3.37 | 4.70 | 4.96 | 1.33 | <.001 | 1.59 | <.001 |
| Interfered with relationships (question 7) | 6.55 | 6.51 | 7.01 | −0.04 | 0.34 | 0.46 | .004 |
| Awakened at night (question 8) | 3.62 | 4.48 | 4.85 | 0.86 | <.001 | 1.23 | <.001 |
| Felt angry about child’s asthma (question 9) | 6.09 | 6.55 | 6.66 | 0.47 | .004 | 0.57 | .003 |
| Felt angry about child’s ability (question 10) | 4.16 | 5.46 | 5.39 | 1.31 | <.001 | 1.24 | <.001 |
| Felt angry about child’s medications (question 11) | 4.55 | 5.55 | 5.74 | 1.00 | <.001 | 1.19 | <.001 |
| Felt angry about being overprotective (question 12) | 4.12 | 4.60 | 5.23 | 0.49 | .004 | 1.12 | <.001 |
| Felt angry about child’s lifestyle (question 13) | 4.58 | 5.43 | 5.66 | 0.85 | <.001 | 1.07 | <.001 |
| Physical activity subscale average (questions 2, 4, 6, and 8) | 4.08 | 5.04 | 5.38 | 0.96 | <.001 | 1.30 | <.001 |
| Emotional health subscale average (questions 1, 3, 5, 7, 9, and 13) | 5.04 | 5.73 | 6.00 | 0.69 | .002 | 0.95 | <.001 |
P values based on Wilcoxon rank test.
Discussion
The goal of this analysis was to evaluate the relative effectiveness of asthma home visits conducted primarily by CHWs, as compared with nurses. The improvement in the 5 outcomes for both groups suggests that the original and CMS models were both successful in supporting effective asthma management for patients enrolled in CAI. This is consistent with previous studies, which have demonstrated significant improvement in health outcomes among patients enrolled in CAI.6,29 For some health outcome measures, the CMS group exhibited additional improvements compared to the comparison group, possibly because of the shift from primarily nurse to CHW home visits. In both models, the CHWs had extensive training, and both models included a full-time nurse practitioner who performed initial assessments, provided clinical supervision for the CHWs in understanding patients’ medical histories and medications, and assisted with care coordination with primary care physicians and specialists, as well as case management and advocacy, as needed.
The goal during both models was to complete 3 home visits per patient; however, there was a stronger emphasis on providing 3 home visits under the CMS model to align with other NEAIC members. After the model shift, the average number of home visits increased significantly from 1.9 to 2.4 visits per family. There are several possible explanations that may have contributed to this increase. First, families may have felt more comfort and connection with the CHWs, given their unique role as trusted members of the community.21,22 Additionally, families were provided with a $20 gift card for completion of all 3 visits. Lastly, the CHWs in the CMS model were less isolated than the original CHW located at a community agency and were able to work as a team within CAI at Boston Children’s. The team also met on a regular basis with other CHWs throughout NEAIC to discuss recruitment and retention strategies. The greater number of home visits for the CMS group allowed for increased opportunities for asthma management support, which may have contributed to the significantly greater improvements demonstrated by the CMS group.
The QoL of the parents and caregivers in the CMS group improved significantly by the 6- and 12-month follow-up. The improvement in parent or caregiver QoL over the course of the CAI intervention suggests that asthma management programs can have a positive impact on the patient’s parents and/or caregivers in addition to the patient. This increase in QoL for parents and caregivers is supported by previous studies in which researchers have suggested that there is a positive correlation between a patient’s asthma control and their parent’s or caregiver’s QoL.13,21,30–33
Studies from other asthma home-visiting programs throughout the United States have indicated that using CHWs as home visitors can improve patients’ asthma control and limit negative health outcomes in areas where the rates of asthma are elevated.21–24,34 By switching to more CHW home visits, programs may also decrease asthma-related costs without a loss of quality or reduction in positive outcomes.25–27,35 In this analysis, both models contained a full-time nurse practitioner who provided in-hospital intakes and close supervision of CHWs, which is more nurse involvement than most other national programs. This was necessary, in part, because patients were enrolled directly from inpatient settings (including the intensive care units) or after multiple ED visits due to moderate to severe asthma exacerbations. In future studies, researchers should evaluate the optimal level of nurse clinical supervision that is needed for an increased CHW role in programs serving asthma patients who have had recent hospitalizations or ED visits.
Limitations of this study include the fact that the original and CMS models took place at 2 different time periods, which may have contributed to differences in asthma incidence and severity between the 2 periods because of seasonal factors, such as variations in viral and influenza seasons. There were also changes in patient demographic data, including age, sex, race and/or ethnicity, and language spoken, as CAI expanded to new low-income areas in Boston over time. In addition, the asthma education provided by the medical home increased throughout the study period, which may have supported patients’ asthma management. Health outcomes of the CMS and comparison groups were not compared with those of patients who were not enrolled in CAI, so the analyses did not take into account changes in asthma control that can result from medical management over time. However, in previous studies of the CAI intervention, our data indicate that patients enrolled in CAI experience significantly greater improvements in health outcomes on the basis of parent or caregiver report, hospital administrative data, and comprehensive claims data.6,27 Additionally, health outcome data were collected by patient and parent and/or caregiver report and were not confirmed by complete hospital or school administrative data. However, we have shown in the past that CAI data obtained through parental report are similar to our hospital’s administrative data.29 Finally, data for parent and/or caregiver QoL were collected during only the CMS model period. Because of this, the impact of the CAI intervention on parent and/or caregiver QoL during the original model, as well as the difference in QoL outcomes between the 2 groups, could not be analyzed. Therefore, we were unable to measure the change between models for parent and/or caregiver QoL.
This study reveals that a program that uses CHWs to conduct home visits under nurse supervision may be as effective, or even more effective, at improving health outcomes as a primarily nurse home-visiting program. The program also gained experience and matured over time, which may have contributed to the improvements in health outcomes in the later phase of the program. We have previously shown that hospitalization costs constitute the largest share of overall health care costs incurred by asthma patients.29 The greater reduction in hospitalization among the CMS group compared to the comparison group is likely to be associated with a significant additional decrease in health care costs among the CMS group. The lower costs associated with maintaining a program with a majority of home visits provided by CHWs instead of nurses may further contribute to the cost-effectiveness of home-visiting programs nationally.
Conclusions
Patients in both the CMS and comparison groups exhibited significantly improved health outcomes for all 5 measures. Under the CMS model, patients showed some additional improvement in health outcomes, including a significantly greater decrease in percentage of hospital admissions, missed school days, and parent and/or caregiver missed workdays at the 12-month follow-up in the final statistical model. Results from these analyses suggest that a nurse-supervised CHW model is just as, if not more, effective at improving patient health outcomes. In addition, parents and caregivers of the CMS group experienced significant improvement in QoL 6 and 12 months after enrollment in CAI, supporting the case that asthma home-visiting programs have a positive impact for family members in addition to patients.
Ms Shreeve conceptualized and designed the study, drafted the initial manuscript, and reviewed and revised the manuscript; Dr Woods conceptualized and designed the study, designed the data collection instruments, and reviewed and revised the manuscript; Ms Sommer conceptualized and designed the study, designed the data collection instruments, coordinated and supervised data collection, and reviewed and revised the manuscript; Ms Lorenzi and Ms Monteiro collected data and reviewed and revised the manuscript; Dr Nethersole conceptualized and designed the study and reviewed the manuscript; Dr Bhaumik conceptualized and designed the study, conducted the analyses, and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: Partially supported by Health Resources in Action’s Centers for Medicare and Medicaid Services (CMS) Innovation Award 1C1CMS331039 (Community Asthma Initiative had a subaward), the Centers for Disease Control and Prevention Racial and Ethnic Approaches to Community Health US Cooperative Agreement grant 1U58DP001055, Healthy Tomorrows Partnership for Children Program H17MC06705 from the Health Resources and Services Administration (HRSA), and Leadership Education in Adolescent Health training grant T71MC00009 (Maternal and Child Health Bureau), HRSA; the Ludke, Covidien, Boston Scientific, and BJ and Thoracic Foundations; and the Boston Children’s Hospital Office of Community Health. The contents are those of the authors and do not necessarily represent the official views of, or an endorsement by, the CMS, Centers for Disease Control and Prevention, HRSA, Department of Health and Human Services, or the US government.
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