Sunset Park Family Health Center Network

Narrative Description of Program

In 1994, the Health Systems Agency designated Sunset Park a Priority One neighborhood because of its high hospitalization rates for asthma and chronic obstructive pulmonary disease.  To address this problem, the Sunset Park Family Health Center Network (FHCN) of Lutheran Medical Center was awarded a two-year $500,000 Primary Care Initiative (PCI) grant from the New York State Department of Health.

To respond to this need, as Asthma Education Program (AEP) was developed with support of the PCI grant.  The new program was directed by FHCN’s Associate Medical Director who had significant experience with asthma.  She immediately recruited the talents of two nurse case managers and two health educators as well as several members of the Community HealthCorps, FHCN’s AmeriCorps program.  A national expert on asthma was engaged as a consultant to help provide feedback, educational inservice to professional staff, and recommend strategy for change in the management of asthma.

For the past two years an institution wide multi-disciplinary Asthma Task Force (ATF) has met on a monthly basis to recommend policy and direction for the AEP.  The efforts made by the ATF has resulted in acceptance of the National Institute of Health Clinical Guidelines for the diagnosis and treatment of asthma, the establishment of linkages between acute care, ambulatory care and the School Health Program, and the development of inpatient and ambulatory care protocols for the treatment of asthma.

Evidence of Community Need

The AEP gathered statistical data showing the distribution for FHCN patients who are diagnosed with asthma and live in zip codes 11220, 11232, and 11215.  In addition, ten of our twelve School Health Program sites are located within the three zip codes.  In 1993, the network’s asthma patient population within the three zip codes was 1.018.  This number increased in 1994 to 1,201and increased again to 1,401 in 1995, a 38.0% increase in two years.

Target Audience

The AEP team targeted the 0-5 age group since this was the group with the highest apparent need.  AEP initiated a Nurse Case Management (NCM) component in the ambulatory care setting starting at the prevention level to work intensely with the targeted age group.  On the team with the NCM are Health Educators who worked with the general asthma patient and introduced a School Asthma Program component at two of FHCN’s School Health Programs with the support of several members of the Community HealthCorps, FHCN’s AmeriCorps program.  Their role was to provide basic knowledge of the functioning of their lungs and pathogenesis of asthma; show the proper use of peak flow meters, MDI, spacers and nebulizers; and provide a better understanding of the prescribed medications and potential triggers.  The staff provided home visits to reinforce teachings as well as to conduct a home environment assessment with the family.

Two educational models were established:  (1) Community Health Education Program using group sessions held in FHCN satellites and (2) School Asthma Program.

Community Health Education Program

Initially, a three-session health education program was established.  Attendance was excellent at the first session, but dropped precipitously for the second and third sessions.  Health educators spent an enormous amount of time on the phone trying to encourage clients to attend sessions and initiate new groups.  As a result, a new strategy was developed which focused on the "teachable moment" model.  Afterwards, one-to-one educational sessions were conducted on the same day patients presented to the health center for asthma care.

The advantage of the 1:1 educational session is the ability to instruct patients at an aged and educationally appropriate level for the patient.  This also allowed for a question and answer period to verify patient understanding.  The AEP staff continues to hold group sessions to increase visibility and to reach people who might not otherwise come in contact with the health education staff.  Patient incentives to increase participation include T-shirts, hats, water bottles and even child care.

School Asthma Program

The School Asthma Program (SAP) was designed to introduce the Asthma Education Program to students who were enrolled in the School Health Program.  P.S. 314 and Dewey JHS participated in this innovative project.

Students were taught how to be aware of their respiratory system and how to avoid and control environmental factors that can trigger an asthma episode.  Students who participate in SAP have the opportunity to practice and demonstrate their skill development on use of peak flow meters, metered dose inhalers and spacers for asthma management.  SAP incorporates decision-making and problem-solving activities into the curriculum to enable both parents and students to acquire the skills needed for appropriate asthma management.  By participating in SAP, students learned the importance of preventive care and its influence on the outcome of asthma.

Program Objectives and Goals

The goal of the AEP was to develop a Network-wide primary care approach to the care of asthma patients.  A second goal for the AEP was the development of a culturally sensitive patient education curriculum to address parental concerns and assist them in developing skills to control their children’s asthma.  Ultimately, the outcome goals are to increase parental knowledge about asthma, decrease utilization of emergency department and walk-in visits, along with decrease admissions related to asthma exacerbations.

As of December 1996, a total of 704 asthma patients were referred to the AEP and 95% of these patients have been successfully contacted by AEP staff.  In 1996, a cost analysis on utilization of emergency room, walk-in and hospitalizations was conducted on a sample of 89 patients who had received asthma education, durable medical equipment, home treatment plans, or nurse case management.  The analysis showed as estimated cost savings of $191,800.00.

Table 2 shows a cost savings of $170,875.000 on a randomized chart review of 50 cases in the 0-5 age group.  The charts were reviewed for utilization of emergency room walk-in and hospitalization six months prior to NCM intervention and utilization six months after intervention.  The findings after NCM intervention are significant, there was a 87% decrease in Emergency Department (ED) visits, a 77% decrease in Walk-In (WI) visits, and 84% decrease in hospital admissions.  The same utilization criteria was used for a second chart review (Table 3) on a sample of 39 cases in the 1-11 age group who attended health education sessions provided by our health educators and showed a cost savings of $20,925.00.

Table 2:  Age Group:  <5 years of age
Asthma Program Cost Analysis Report
Total patients case managed by RN for at least six months:  50

Cost Savings r/t case management:  $170,875.52

Table 3:  Age group: 1-11 years of age
Patients who only attended  Asthma Education Sessions
Sessions Conducted by Health Educators, no RN case management
Total number of patients:  39

Cost Savings r/t Asthma Education ONLY:  $20,925.76
Source:  * FHC Billing:  January-June 1996 Cost Analysis Report
**1995 LMC ICR Cost Report

The interventions provided by the AEP have been so successful, that the targeted age group has been expanded to the 1-21 age range.  The AEP will continue to perform chart reviews on utilization before and after intervention to measure outcomes in 1997.  In an attempt to project future cost savings, 1,219 enrolled Health Plus (capitated patients) age 0-18 with the diagnosis of asthma was identified.  In 1995, these patients averaged 10.75 visits per patient in the ambulatory care setting costing the FHCN an estimated $1,359,929.  Applying the experience gained using case management and health education by the AEP team, a 30% reduction in unscheduled visits and hospitalizations would generate a cost savings of $407,978.

• The Asthma Education Program worked closely with the Community HealthCorps and AmeriCorps program of the Sunset Park Family Health Center Network

The Sunset Park asthma population escalated 38% in just two years, and the hospitalization rate for children was four times the national average.  The Asthma Education Program (AEP) increased the understanding of patients and their parents in assessment, preventive and self-care skills, so that after six months emergency department visits decreased 87%, walk-ins 77%, and hospitalizations 84%.

Specific Comments Included: An effective single disease focus with strong community outreach.  Remarkably large effects of two modes of intervention in a well-designed chart review of emergency room visits, walk-in visits and hospitalizations before and after intervention.  Convincing evidence for cost savings from case management method and for education method.  Excellent potential for replication.  Excellent use of culturally appropriate education.

A community Asthma Education Program was developed for 0-11 year old children in high priority neighborhood with a state grant.  The multi-faceted program included case management, community education, and school health education components.  There were large decreases in health services use for asthma.  Cost data are quite convincing, as are the positive medical outcomes.  A much needed chronic disease management program.  The targeted 0-5 age group has yielded the greatest impact.  The School Asthma Program is a skills building, preventive intervention with a parent component included.  There is an outreach to individuals post-episode, inviting them to join an educational program.  The program materials are creative and appealing.  The intervention yielded strong results.  A great strength is that the program goes to schools to teach the youth.  There is a solid cost analysis report.

Concerns mentioned included:  Experimental design does not allow secular effects, regression to the mean, or age effects to be ruled out as confounders.  The level of participation of the eligible people appears somewhat weak.  There is a relatively short time horizon for the study, which is a before and after comparison.  The program could be strengthened by going after parental smoking behaviors.  Cost savings are estimates.  Documentation consists mostly of articles and newsletters and the program remains relatively small with a total of 50 in one group and 39 in the other.