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The Lawndale Christian Health Center Asthma Education Program
The Lawndale Christian Health Center Asthma Education Program* Florence Roque; Loretta Walker; Pat Herrod; Toni Pyzik; and William Clapp, MD
(CHEST 1999; 116:201S–202S) Abbreviation: LCHC 5 Lawndale Christian Health Center
National Asthma Education Prevention Program T heExpert Panel Report 2 guidelines describe four components necessary for an effective asthma management program. The fourth component emphasizes that “education for active partnership with patients remains the cornerstone of asthma management.”1 Lawndale Christian Health Center (LCHC) has developed an asthma education program that emphasizes the importance of developing trusting relationships leading to partnerships that can result in effective education. LCHC was founded in 1984 as a ministry of Lawndale Community Church, for the purpose of demonstrating God’s love by providing high-quality, affordable health care to the medically underserved Lawndale community of Chicago, IL. In 1990, LCHC became a Federally Qualified Heath Center and was designated as a 330 Health Care Site in 1992. The patient volume has grown from 4,000 patient visits in 1984 to . 65,000 in 1997. Two asthma educators coordinate the asthma education program. They both live in neighborhoods serviced by the clinic, and were originally hired as support staff. They have received training in asthma and asthma management, have personal experience with asthma, and, very importantly, bring substantial relational expertise to the position. The LCHC asthma program has three major components: (1) a weekly asthma clinic; (2) home visits; and (3) asthma seminars.
Weekly Asthma Clinic Patients with asthma are scheduled for regular follow-up visits during a weekly asthma clinic. In order to emphasize the importance of regular visits and improve attendance, the asthma educators contact the patients beforehand to remind them of their clinic appointments. At the clinic visit, the asthma educator takes a history using a standardized form designed to elicit details about asthma severity, triggers, and exposures. After a focused physical examination by a pulmonary physician (for adults) or a pediatric nurse practitioner (for children), the asthma educator reviews topics tailored to the patient’s needs. These topics include basic respiratory anatomy and physiology; basic asthma *From the Lawndale Christian Health Center, Chicago, IL. Supported by a grant from the Otho S.A. Sprague Memorial Institute. Correspondence to: William Clapp, MD, Lawndale Christian Health Center, 3860 W Ogden Ave, Chicago, IL 60623
pathophysiology; triggers and trigger control; purpose and administration of medications; use of metered-dose inhalers and spacers; use of nebulizers; and use of peak flowmeters. The patient leaves with an information packet and customized printed instructions, including an action plan. The instructions include names and contact numbers of the health-care providers and a pager that patients can call if they run out of medicines or need help during off hours. When the patient returns to the clinic, this information is reviewed and, if necessary, reinforced.
Home Visits Often patients find it difficult to come in for their scheduled office visits.2 In such situations, the asthma educators make home visits. This is particularly helpful for caregivers with many children, ill patients who have recently been discharged from the hospital, patients for whom repeated reinforcement of the educational messages is particularly important,2 and for patients who can’t seem to make it into the clinic for other reasons. The home visit also provides an opportunity for the asthma educator to conduct an environmental assessment. Most importantly, home visits help patients feel that they have a caring resource that is helpful and accessible, which contributes to a relationship of trust.
Asthma Seminars In the third component of the program, half-day asthma seminars are presented to patients, their families, and other people with asthma in the neighborhood. Speakers have included LCHC asthma educators, respiratory therapists, an expert on nontoxic cockroach control, outreach workers, and a nurse from LCHC. Stories and experiences have been shared by members of the community and discussion has been led by the Chicago Health Connection, a group that is interested in developing community-based support networks. The seminars are festive events, with meals, incentives, and door prizes for the participants. In addition to disseminating knowledge about asthma, the seminars also encourage the development of supportive relationships among asthma patients, their families, and other people with asthma in the community.
Figure 1. Responses to question, “Has asthma resulted in any of these occurrences in the prior 4 weeks?” Data represent number of patients who replied “yes” (n 5 30). ER 5 emergency room; Wrk 5 work; Schl 5 school. CHEST / 116 / 4 / OCTOBER, 1999 SUPPLEMENT
201S
Impact Study To evaluate the impact of the asthma education program, a questionnaire was administered to adults that addressed asthma-related absenteeism, emergency room visits, and hospitalization. The Scale for Measurement of Quality of Life in Adults with Asthma3 was also included. The questionnaires were administered at the first asthma clinic visit and repeated at 3 months or later. Significant improvements were found for a number of the quality-oflife questions (data not shown). Asthma morbidity also improved, with fewer patients requiring hospitalization or emergency care in the 4 weeks prior to the second questionnaire (Fig 1).
Discussion For many reasons, health education is difficult in medically underserved urban communities. Many patients have a history of bad experiences with the health-care system,4 resulting in a reluctance to develop true partnership with any health-care provider. Moreover, many people with asthma have had such negative educational experiences in the past that they are resistant to formalized educational efforts. These issues can make educational clinic appointments uncomfortable, and make routine follow-up difficult for many patients. LCHC has found that to develop the foundation of trust necessary for partnership and education, a highly personalized, one-on-one approach is important. The asthma educators fulfill a role that is in many ways similar to a case manager. Because the educators are from the community, they are viewed as respected peers and are thus able to communicate and reinforce the elements of asthma care with greater efficacy than a provider of a different educational and cultural background. Importantly, concern for the emotional and spiritual well-being of the person with asthma significantly enhances the asthma educator’s credibility. Furthermore, the asthma educators frequently elicit critical information about a person’s environment and habits that many physicians or nurse practitioners would have difficulty obtaining. This can lead to referral to address issues such as substance abuse, domestic violence, or unfit housing. Indoor air quality remains one of the most difficult aspects to improve; while a number of approaches may be very helpful, some patients may require relocation. Although third-party payers are reluctant to expend resources on these sorts of preventive measures, this highly personalized approach is helpful in reducing morbidity. Hopefully, this will be shown to be financially worthwhile and therefore sustainable. Until such time, such programs will require funding from other sources. In summary, medically underserved communities have motivated, capable people who can help bridge the distance between a dauntingly complex and somewhat indifferent health-care system and appropriately skeptical members of the community.4 With their guidance, 202S
trusting relationships can be built to allow development of an essential partnership for effective asthma education.
References 1 National Asthma Education and Prevention Program. Expert panel report 2: guidelines for the diagnosis and management of asthma. Bethesda, MD: National Institutes of Health, April 1997; Publication No. 97– 4051 2 Evans R. Asthma among minority children: a growing problem. Chest 1992; 101(suppl):368S–371S 3 Marks GB, Dunn SM, Woolcock AJ. A scale for measurement of quality of life in adults with asthma. J Clin Epidemiol 1992; 45:461– 472 4 Abraham LK. Mama might be better off dead: the failure of health care in urban America. Chicago, IL: University of Chicago Press, 1993
The Infant Welfare Society’s Asthma Management Project* Diana Wright, ND, CPNP
(CHEST 1999; 116:202S–203S) Infant Welfare Society is a large, Chicago-based T hecommunity health center serving indigent women and
children. Since the turn of the century, its mission has been to “provide services for the healthy physical and mental development of disadvantaged children to give them a foundation for a productive future and wholesome life.” In fulfillment of its mission, Infant Welfare provides comprehensive primary care to children from birth through the age of 19 years. The health center also provides prenatal and gynecologic care to women, and offers mental health and dental services as well. Although the services are open to all, Infant Welfare’s patients are predominantly Hispanic; many are recent immigrants and do not speak English. Services are delivered by three pediatricians and four nurse practitioners. During the last few years, the staff at the Infant Welfare Health Center perceived an increase in the number of patients with asthma. At the same time, they found themselves inadequately prepared to provide asthma education and support that was bilingual and culturally sensitive. In 1996, Infant Welfare began to receive asthma-specific funding from two local philanthropic organizations. While one of the awards is primarily dedicated to covering the costs of providing patients with free asthma medications, spacers, and peak flowmeters, both awards have made it possible for Infant Welfare to develop a comprehensive asthma management program. At the start, the funds covered the services of a pediatri-
*From The Infant Welfare Society of Chicago, Chicago, IL. The Asthma Management Project of the Infant Welfare Society of Chicago is funded by grants from the Otho S.A. Sprague Memorial Institute and the Lloyd A. Fry Foundation. Correspondence to: Diana Wright, ND, CPNP, The Infant Welfare Society of Chicago, 1931 N Halsted St, Chicago, IL 60614 Asthma in Chicago
(CHEST 1999; 116:201S–202S) Abbreviation: LCHC 5 Lawndale Christian Health Center
National Asthma Education Prevention Program T heExpert Panel Report 2 guidelines describe four components necessary for an effective asthma management program. The fourth component emphasizes that “education for active partnership with patients remains the cornerstone of asthma management.”1 Lawndale Christian Health Center (LCHC) has developed an asthma education program that emphasizes the importance of developing trusting relationships leading to partnerships that can result in effective education. LCHC was founded in 1984 as a ministry of Lawndale Community Church, for the purpose of demonstrating God’s love by providing high-quality, affordable health care to the medically underserved Lawndale community of Chicago, IL. In 1990, LCHC became a Federally Qualified Heath Center and was designated as a 330 Health Care Site in 1992. The patient volume has grown from 4,000 patient visits in 1984 to . 65,000 in 1997. Two asthma educators coordinate the asthma education program. They both live in neighborhoods serviced by the clinic, and were originally hired as support staff. They have received training in asthma and asthma management, have personal experience with asthma, and, very importantly, bring substantial relational expertise to the position. The LCHC asthma program has three major components: (1) a weekly asthma clinic; (2) home visits; and (3) asthma seminars.
Weekly Asthma Clinic Patients with asthma are scheduled for regular follow-up visits during a weekly asthma clinic. In order to emphasize the importance of regular visits and improve attendance, the asthma educators contact the patients beforehand to remind them of their clinic appointments. At the clinic visit, the asthma educator takes a history using a standardized form designed to elicit details about asthma severity, triggers, and exposures. After a focused physical examination by a pulmonary physician (for adults) or a pediatric nurse practitioner (for children), the asthma educator reviews topics tailored to the patient’s needs. These topics include basic respiratory anatomy and physiology; basic asthma *From the Lawndale Christian Health Center, Chicago, IL. Supported by a grant from the Otho S.A. Sprague Memorial Institute. Correspondence to: William Clapp, MD, Lawndale Christian Health Center, 3860 W Ogden Ave, Chicago, IL 60623
pathophysiology; triggers and trigger control; purpose and administration of medications; use of metered-dose inhalers and spacers; use of nebulizers; and use of peak flowmeters. The patient leaves with an information packet and customized printed instructions, including an action plan. The instructions include names and contact numbers of the health-care providers and a pager that patients can call if they run out of medicines or need help during off hours. When the patient returns to the clinic, this information is reviewed and, if necessary, reinforced.
Home Visits Often patients find it difficult to come in for their scheduled office visits.2 In such situations, the asthma educators make home visits. This is particularly helpful for caregivers with many children, ill patients who have recently been discharged from the hospital, patients for whom repeated reinforcement of the educational messages is particularly important,2 and for patients who can’t seem to make it into the clinic for other reasons. The home visit also provides an opportunity for the asthma educator to conduct an environmental assessment. Most importantly, home visits help patients feel that they have a caring resource that is helpful and accessible, which contributes to a relationship of trust.
Asthma Seminars In the third component of the program, half-day asthma seminars are presented to patients, their families, and other people with asthma in the neighborhood. Speakers have included LCHC asthma educators, respiratory therapists, an expert on nontoxic cockroach control, outreach workers, and a nurse from LCHC. Stories and experiences have been shared by members of the community and discussion has been led by the Chicago Health Connection, a group that is interested in developing community-based support networks. The seminars are festive events, with meals, incentives, and door prizes for the participants. In addition to disseminating knowledge about asthma, the seminars also encourage the development of supportive relationships among asthma patients, their families, and other people with asthma in the community.
Figure 1. Responses to question, “Has asthma resulted in any of these occurrences in the prior 4 weeks?” Data represent number of patients who replied “yes” (n 5 30). ER 5 emergency room; Wrk 5 work; Schl 5 school. CHEST / 116 / 4 / OCTOBER, 1999 SUPPLEMENT
201S
Impact Study To evaluate the impact of the asthma education program, a questionnaire was administered to adults that addressed asthma-related absenteeism, emergency room visits, and hospitalization. The Scale for Measurement of Quality of Life in Adults with Asthma3 was also included. The questionnaires were administered at the first asthma clinic visit and repeated at 3 months or later. Significant improvements were found for a number of the quality-oflife questions (data not shown). Asthma morbidity also improved, with fewer patients requiring hospitalization or emergency care in the 4 weeks prior to the second questionnaire (Fig 1).
Discussion For many reasons, health education is difficult in medically underserved urban communities. Many patients have a history of bad experiences with the health-care system,4 resulting in a reluctance to develop true partnership with any health-care provider. Moreover, many people with asthma have had such negative educational experiences in the past that they are resistant to formalized educational efforts. These issues can make educational clinic appointments uncomfortable, and make routine follow-up difficult for many patients. LCHC has found that to develop the foundation of trust necessary for partnership and education, a highly personalized, one-on-one approach is important. The asthma educators fulfill a role that is in many ways similar to a case manager. Because the educators are from the community, they are viewed as respected peers and are thus able to communicate and reinforce the elements of asthma care with greater efficacy than a provider of a different educational and cultural background. Importantly, concern for the emotional and spiritual well-being of the person with asthma significantly enhances the asthma educator’s credibility. Furthermore, the asthma educators frequently elicit critical information about a person’s environment and habits that many physicians or nurse practitioners would have difficulty obtaining. This can lead to referral to address issues such as substance abuse, domestic violence, or unfit housing. Indoor air quality remains one of the most difficult aspects to improve; while a number of approaches may be very helpful, some patients may require relocation. Although third-party payers are reluctant to expend resources on these sorts of preventive measures, this highly personalized approach is helpful in reducing morbidity. Hopefully, this will be shown to be financially worthwhile and therefore sustainable. Until such time, such programs will require funding from other sources. In summary, medically underserved communities have motivated, capable people who can help bridge the distance between a dauntingly complex and somewhat indifferent health-care system and appropriately skeptical members of the community.4 With their guidance, 202S
trusting relationships can be built to allow development of an essential partnership for effective asthma education.
References 1 National Asthma Education and Prevention Program. Expert panel report 2: guidelines for the diagnosis and management of asthma. Bethesda, MD: National Institutes of Health, April 1997; Publication No. 97– 4051 2 Evans R. Asthma among minority children: a growing problem. Chest 1992; 101(suppl):368S–371S 3 Marks GB, Dunn SM, Woolcock AJ. A scale for measurement of quality of life in adults with asthma. J Clin Epidemiol 1992; 45:461– 472 4 Abraham LK. Mama might be better off dead: the failure of health care in urban America. Chicago, IL: University of Chicago Press, 1993
The Infant Welfare Society’s Asthma Management Project* Diana Wright, ND, CPNP
(CHEST 1999; 116:202S–203S) Infant Welfare Society is a large, Chicago-based T hecommunity health center serving indigent women and
children. Since the turn of the century, its mission has been to “provide services for the healthy physical and mental development of disadvantaged children to give them a foundation for a productive future and wholesome life.” In fulfillment of its mission, Infant Welfare provides comprehensive primary care to children from birth through the age of 19 years. The health center also provides prenatal and gynecologic care to women, and offers mental health and dental services as well. Although the services are open to all, Infant Welfare’s patients are predominantly Hispanic; many are recent immigrants and do not speak English. Services are delivered by three pediatricians and four nurse practitioners. During the last few years, the staff at the Infant Welfare Health Center perceived an increase in the number of patients with asthma. At the same time, they found themselves inadequately prepared to provide asthma education and support that was bilingual and culturally sensitive. In 1996, Infant Welfare began to receive asthma-specific funding from two local philanthropic organizations. While one of the awards is primarily dedicated to covering the costs of providing patients with free asthma medications, spacers, and peak flowmeters, both awards have made it possible for Infant Welfare to develop a comprehensive asthma management program. At the start, the funds covered the services of a pediatri-
*From The Infant Welfare Society of Chicago, Chicago, IL. The Asthma Management Project of the Infant Welfare Society of Chicago is funded by grants from the Otho S.A. Sprague Memorial Institute and the Lloyd A. Fry Foundation. Correspondence to: Diana Wright, ND, CPNP, The Infant Welfare Society of Chicago, 1931 N Halsted St, Chicago, IL 60614 Asthma in Chicago