By Angela Cochran, Director, Chronic Disease Prevention & Control, St. Mary’s County Health Department
Editor’s Note: NACCHO recognized St. Mary’s County’s Asthma Control Program as a 2017 Model Practice. St. Mary’s County shared this post with updates on their successful asthma intervention in honor of National Asthma and Allergy Awareness Month in May.
Asthma accounts for almost two million emergency department (ED) visits each year in the U.S. It is the leading cause of school absenteeism, resulting in 10.5 million missed school days annually, and it is the third leading cause of hospitalization among children under 15. In St. Mary’s County in Maryland, the childhood asthma prevalence is 13.7%, higher than the state average of 10.3%. Asthma is a serious and chronic respiratory problem with no known cure and limited treatment options, which makes it a pressing public health concern.
The Asthma Control Program (ACP) at the St. Mary’s County Health Department (SMCHD) launched in 2014, and it utilizes a certified asthma nurse educator to make free home visits to referred patients. Outreach continues with local pediatricians, family physicians, nurse practitioners, pediatric subspecialists, emergency department staff, and school nurses to announce the initiative.
Families and caregivers are contacted upon referral for an intake appointment, including baseline health measures. If families are receptive, an in-home visit is scheduled, where the educator reviews asthma medications and the written asthma action plan, provides asthma education, completes an environmental scan of the home to identify triggers, and offers minor-to moderate environmental remediation supplies. Follow-up phone calls are conducted with the family/caregiver at 3, 6, and 12 months after the home visit. Written follow-up is provided to the primary care clinician, school nurse, and relevant subspecialty clinician.
The ACP initiative applies the evidence-based public health practice of home-based, multi-trigger, and multi-component interventions with an environmental focus for children and adolescents ages 2–18 with asthma. The project goals of the program include the following:
- Reduce home exposure to multiple indoor asthma triggers (allergens and irritants) for children ages 2–18 with asthma living in St. Mary’s County.
- Provide general asthma education within the home setting for families of children with asthma.
- Promote the utilization of written asthma action plans by children with asthma, their families/caregivers, primary care providers, and school nurses.
- Promote smoking cessation for persons living in a home occupied by a child/adolescent with asthma.
- Decrease the number of emergency department visits, hospitalizations, missed school days, and courses of oral steroids due to asthma.
All program objectives were met through the home visiting program. As of May 2018, educators have made over 100 home visits to patients ages 2–18. The involved children have collectively demonstrated significant reductions in emergency department visits, hospitalizations, missed school days, and courses of oral steroids due to asthma.
For those patients who completed the one-year follow-up for the program, emergency department visits related to asthma decreased by 87%, in-patient hospital stays decreased by 93%, use of oral steroids courses decreased by 69%, and missed school days decreased by 69%.
The success of the practice was due to
- having an asthma certified nurse conduct the initial home visit and having follow-up contact with the families after the visit;
- the supplies distributed, which helped both in getting families to participate and in reducing the triggers;
- an agreement with a Medicaid MCO, which, for the time it existed, helped identify potential children who would benefit;
- school nurse involvement to help encourage families to participate; and
- a partnership with a local hospital ED to provide referrals for youth seen in the ED for asthma.
Sustainability of the program relies not only on funding but also on referrals from community partners. Referrals are received from the local hospital and county school system, as well as through a referral system implemented by the St. Mary’s County Primary Care Collaborative (SMCPCC). Primary care practices that utilize the community-clinical linkages referral form can refer patients to the ACP. Any local provider or non-provider can refer to the ACP, but use of the SMCPCC is an innovative approach to receive referrals. Additionally, the ACP provides feedback and communication to local school nurses and physicians on residents who we have seen for a home visit. This feedback loop is essential to support the continuum of care.
The ACP has expanded from having only one nurse educator to also staffing two Community Health Outreach Workers to support with follow-up visits and community education. As the program has evolved, multiple funding sources have been utilized. The Maryland Department of Health (MDH) and local grant funds covered costs at the beginning of the initiative, and for a time, the ACP contracted with a regional Medicaid Managed Care Organization to receive referrals and reimbursement for the environmental supplies provided to their clients. Currently, funding is provided through the MDH, Office of Minority Health and Health Disparities and the Environmental Health Bureau.
- Moorman JE, Akinbami LJ, Bailey CM, et al. National Surveillance of Asthma: United States, 2001–2010. National Center for Health Statistics. Vital Health Stat 3(35). 2012.
- Maryland Department of Health and Mental Hygiene. Annual Trend in Current Asthma Prevalence Among Children (0-17 years) BRFSS, 2011-2012 aggregated. 2014.
- Guide to Community Preventive Services. Asthma: Home-Based Multi-Trigger, Multicomponent Environmental Interventions – Children and Adolescents with Asthma. https://www.thecommunityguide.org/findings/asthma-home-based-multi-trigger-multicomponent-environmental-interventions-children-and. Page last updated: November 08, 2017.