YES WE CAN Children’s Asthma Program

This case study was prepared for CDC by Dr. LaMar Palmer of MAS Consultants. The purpose of the case study is to share the experience of one community as they attempt to address the problem of asthma. It does not represent an endorsement of this approach by CDC.

YES WE CAN Children’s Asthma Program: Design and Development

Awareness of results from the Bayview/Hunter’s Point survey galvanized the YES WE CAN partners’ resolve to initiate its children’s asthma program as soon as possible. A review of existing literature on community-based intervention programs for inner-city families was undertaken. Collaborative exchanges with staff members of inner-city pediatric asthma programs in New York City and Seattle that used community health workers provided needed insight and lessons learned. Results from the Odessa Brown Children’s Clinic Asthma Outreach Project in Seattle, along with encouragement and assistance from the project’s director, Dr. James Stout, and LaTonya Rogers, a highly experienced community health worker at the clinic, reassured the Community Health Works director and staff that the YES WE CAN model would work in San Francisco (Stout J et al, Asthma Outreach Project 1998). With a sound understanding of other inner-city asthma programs and their operations, and with encouragement and validation from their peers, the founding partners moved ahead with their own project.

One of the original YES WE CAN partners, KP/NC, had extensive experience implementing a chronic care model for its asthma patients. KP/NC is the country’s largest private-sector provider of health care, insuring over three million people in Northern California--nearly one out of four Californians (Lohr, S, Is Kaiser the Future of American Health Care, NY Times, October 31, 2004). KP/NC possessed a rich databank containing 26,000 high risk asthma patients whose condition had been tracked for several years. The benefits of Kaiser Permananente’s new integrated care system for asthma included improved health outcomes, improved member satisfaction, reduction in emergency department (ED) visits and hospitalization rates, and sustainable practice for physicians and other health professionals. KP/NC’s chronic care model for asthma incorporated the following:

1. principles of evidence-based medicine
2. the National Asthma Education and Prevention Program (NAEPP) Guidelines for the diagnosis and management of asthma
3. a risk stratification scheme targeting high-risk children to focus clinical attention on patients with the most severe asthma symptoms
4. a multidisciplinary team delivery of care model
5. high quality clinical care systems with feedback loops and close care management
6. a proven self-management approach for patients.

KP/NC agreed to share its asthma chronic care management program model with its partners for use in the YES WE CAN demonstration project. This model of asthma care would be the keystone of the program. The YES WE CAN partners adopted and modified this prevention-oriented program. According to Deidre Epps-Miller, principal investigator of the Bayview/Hunter’s Point asthma study and co-founder of the San Francisco YES WE CAN, "You need to have collaboration with an organization like Kaiser Permanente who has the systematic protocols that can be adopted for a new demonstration program. It was very generous of them to share these openly with us."

Other partners provided important architectural components and needed infrastructure.

Community Health Works bridges between researchers and communities to facilitate the transition from science to community application. The organization is skilled at translating research advances into practical methods that communities can put to immediate use. Community Health Works staff members also designed and taught the first college credit Community Health Worker Certification Program in the country at the City College of San Francisco (CCSF). These certified CHW graduates find employment working in medically underserved communities. Community Health Works introduced the CHW component to the adopted KP chronic condition management model for asthma.

The San Francisco Department of Health (SFDPH), the largest health care provider for underserved children in the county, co-chaired the San Francisco YES WE CAN Steering Committee. SFDPH, through the Community Health Network of San Francisco, operates 17 health centers and clinics that serve people on Medi-Cal or people who are uninsured. Six of the 17 centers are located at San Francisco General Hospital (SFGH), affiliated with the University of California at San Francisco Medical Center. The SFDPH management team had a vested interest in the welfare of the city’s children with asthma. SFDPH through SFGH would provide the clinical facilities and fund some medical staff time needed for the program.

In January 1999, Community Health Works and its partners received a three-year grant of nearly one million dollars from The California Endowment. This money allowed the San Francisco YES WE CAN Children’s Asthma Program to obtain space and acquire staff time needed to implement the program. The Pediatric Asthma Clinic at SFGH was selected as the first demonstration site.

The target population for the original demonstration project was low-income, inner-city children in San Francisco who had poorly controlled asthma. Services at the Pediatric Asthma Clinic began in late spring of 1999. The clinic had been offering optimal asthma care from early 1998. The YES WE CAN demonstration project added community health workers and a collaborative process to that program that helped enrich the work the clinic already had underway. To date, the YES WE CAN program at the three clinics has treated and instructed approximately 900 children. About 600 children have graduated from the program. Referrals to YES WE CAN come from emergency departments (EDs), urgent care centers, hospitals, primary care physicians, and the community. All high-risk children are eligible for the program; these children are defined as having had an asthma-related ED visit or hospitalization in the previous 6 months and/or use of six or more canisters of beta-agonists (short-acting bronchodilator medication) in the prior 6 months.

The objective of the program is to provide quality medical care, asthma self-management instruction, and practical environmental assistance and to remove those barriers that prevent good asthma self-management by implementing a medical/social team model of prevention-oriented care.

The team is comprised of a clinician who is a physician or nurse practitioner, a clinical care manager who is generally a registered nurse, and a community health worker (CHW). Together, they join with the families of enrolled children to forge a partnership to gain control of the child’s asthma, reduce asthma symptoms, and improve the child’s quality of life.

The work necessary to meet the goal of controlling the child’s asthma is carried out in two settings; an asthma clinic and the patient’s home. Typically the child will have two to three planned asthma clinic visits spread over a 6 - 8 month period. At the clinic, the child undergoes a physical examination, a health history is acquired, asthma symptoms are documented, the diagnosis of asthma is confirmed or established, allergy testing is performed, and asthma education is initiated. The clinic visits are typically interspersed with one to three home visits by the CHW to respond to questions, reinforce asthma education, verify medication adherence, help the family reduce environmental triggers in the home, and address issues that adversely affect the family’s ability to manage the child’s asthma. Sandwiched between these clinic visits and home visits are clinical assessment telephone calls from the clinical case manager to the parent or caregiver to assess asthma control, determine causes of sub-optimal control, and help the caregiver solve problems.

The San Francisco YES WE CAN children’s asthma program formally opened for business in January 1999. Initially the clinic operated just one-half a day each week. A total of 193 visits occurred during the first year. By 2002, the YES WE CAN clinic at SFGH was operating three half-days a week and logged over 500 visits a year. By the end of 2003, more than 1,600 total visits for asthma appeared on the clinic’s Access database. Following the initial demonstration project at the publicly-funded SFGH, the YES WE CAN partners replicated their asthma program at two federally funded community health clinics, the Mission Neighborhood Health Center, starting in 2001, and the Excelsior Clinic, starting in 2002.

The Mission Neighborhood Health Center was designated as the federally funded neighborhood health clinic in the Mission District in 1967. It is the only community-based health center in San Francisco to provide linguistically and culturally appropriate, comprehensive primary health care services to the area’s predominantly low-income, Latino population. More than 13,000 patients are registered. About 52% of all clinic care is subsidized through public and private grants and donations. Excelsior is a small satellite clinic of the Mission Neighborhood Health Center that provides health care primarily to patients of Asian/Pacific Island descent. These three YES WE CAN asthma clinics provided care to hundreds of low-income children with asthma in San Francisco.

Because of local success with the program, Community Health Works staff members have developed materials needed to replicate the intervention, Managing Children’s Asthma: The YES WE CAN Toolkit. The main contributors in this work were KP/NC, NICHQ, the Pediatric Asthma Clinic at SFGH, and many of the YES WE CAN Urban Asthma Partnership members. The California Endowment again provided funding. Details about the Toolkit appear in Section X of this case study.