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The Henry Horner Pediatric Asthma Program^*

^* From the Department of Preventive Medicine (Ms. Baier and Mr. Eckenfels), Rush Medical College, Chicago, IL; and the Department of Immunology/Microbiology (Dr. Grant), and the Center for Health Services Research, Rush Primary Care Institute (Dr. Daugherty), Rush-Presbyterian-St. Luke's Medical Center, Chicago, IL.

Correspondence to: Claudia Baier, MPH, Department of Preventive Medicine, Rush Medical College, 1700 W. VanBuren St., Suite, 460, Chicago, IL 60612; e-mail: claudia Baier{at}rush.eduBaier@rush.edu

	Introduction

TOP Introduction Description of Program Program Achievements Challenges and Future Directions References

 
T he Henry Horner Pediatric Asthma Program (HHPAP) is a community-based initiative that both serves the interests of the Henry Horner community and fulfills the service and educational mission of Rush Medical College of Rush-Presbyterian-St. Luke's Medical Center in Chicago. Using community health workers recruited from the target neighborhood, HHPAP has been providing free asthma education and case-management services since February 1994 to families who have children with asthma. It is funded by the Northern Trust Company and Rush-Presbyterian-St. Luke's Medical Center, with office space donated by the Chicago Housing Authority.

	Description of Program

TOP Introduction Description of Program Program Achievements Challenges and Future Directions References

 
Rationale
Henry Horner Homes is a public housing development located within an area of Chicago that is characterized by extreme poverty, high unemployment, and high infant mortality, and has been shown to have asthma mortality rates among the highest in the nation.¹ Although three major medical centers are located within the same community area, the residents of Henry Horner Homes often do not receive the medical and social assistance they need to manage their asthma.

History
Because of a program at Rush Medical College in which medical students volunteer to provide community services,² relationships developed between the students who tutor children in the Henry Horner housing development, their parents, and a number of community representatives who requested assistance with asthma management. To satisfy this need, community members were identified and hired to serve as community asthma workers (CAWs). Rush faculty, medical students, and representatives from other health and social service occupations provided the initial training on asthma and allergies, case management, health-care systems, and interpersonal communications.

There has been minimal staff turnover since the start of the program. In fact, there are currently four CAWs who have staffed the program an average of 3.6 years.

Participants
The program maintains a case load of 50 children, ranging in age from 2 to 12 years, who are divided among four CAWs. Typically, the case load includes twice as many boys as girls, with two thirds having moderate-to-severe asthma as measured by National Heart, Lung, and Blood Institute criteria, past medical history, and peak flowmeter readings. Often there are two to three children with asthma from the same family. At program implementation, 34 families identified some form of primary health-care provider; however, since the introduction of managed care in Illinois, families report more confusion and less continuity of care.

Activities
The CAWs perform weekly home visits with families. During these visits, they provide the following: (1) education about asthma, allergens, triggers, medications, and self-management; (2) case management linking families to health and social service agencies to increase effective utilization of existing resources; and (3) transportation and child care when necessary to enable families to keep health-care appointments. The CAWs accompany families when they visit their provider to assist with the navigation of the health-care system as needed. They also facilitate support groups for the participants with Rush medical students. In the summer, they coordinate a 4-day summer asthma camp.

As families progress through the program, the CAWs track certain criteria that reflect an increase in asthma knowledge and self-care skill. These criteria, used to evaluate the participant's readiness to graduate from the program, include decreases in asthma symptom days and attacks, fewer emergency department visits and hospitalizations because of asthma, and consistent primary care utilization. The child must also have an emergency plan prescribed by his or her primary care provider before graduation. Home visits to the families decrease gradually as the family satisfies these criteria. After graduation, which is celebrated with the family and the program staff, children and families are encouraged to keep in contact with their CAW as needed or desired.

	Program Achievements

TOP Introduction Description of Program Program Achievements Challenges and Future Directions References

 
Since 1994, the HHPAP has been able to document barriers to asthma management that affect the ability of families to gain access to care and that often contribute to a home environment that is less than optimal for the control of asthma. The CAWs have documented common problems that plague the families in this community, including multiple sick children in the household, limits on daily activity because of violence in the community, substance abuse and smoking in or near the household, inability to purchase adequate food and clothing, lack of communication between caregivers and school personnel, and overcrowded, poorly maintained living conditions. Many families also report problems with other areas of health care, including lack of knowledge about or access to medications and equipment, misunderstandings about insurance coverage or lack of coverage, difficulty reaching a provider and scheduling appointments, and dislike for the primary care provider.

Since 1994, 18 children have graduated from the program and five families have withdrawn. Thirty-four percent have been lost to follow-up, primarily because of relocation efforts initiated by the Chicago Housing Authority's "rehabilitation" of the neighborhood. The length of participation in the program averages 15 months. The most difficult component of the CAWs' responsibilities is meeting and following up with the participants. However, the families keep 82% of the scheduled home visit appointments, averaging 2.6 completed visits per family per month.

Community acceptance of the program has been evident from the beginning. The program has received the following: referrals from area health and social service agencies and schools; requests for information and presentations by individuals, neighborhood groups, and local, state, and national institutions; invitations to present at national meetings; nominations for committee representation; and donations of resources and office space from a variety of public and private organizations. In fact, the CAWs are recognized throughout their community as "the Asthma Ladies," and are seen as sources of information and referral on a variety of citywide health, social service, community, and political issues.

In addition to providing services to the participants and employment for the CAWs, this program allows medical and nursing students to have hands-on volunteer opportunities from which they can learn about a chronic illness from a community-based perspective. By working with the CAWs, students directly observe the effect of illness on the daily lives of children, families, and the community as a whole. They often develop close relationships with families that are usually considered "unreachable" by the traditional health-care system. By working directly with the community residents, they gain a better sense of the multidimensional problems and barriers that often result in episodic care, undertreatment, and poor outcomes.

	Challenges and Future Directions

TOP Introduction Description of Program Program Achievements Challenges and Future Directions References

 
As with most community-based programs, the HHPAP has been challenged by the recruitment and retention of participants whose lives are negatively impacted by political and social change. Securing funding is an additional challenge, and often competes for time that could otherwise be spent on improvement of services. More work needs to be done on the evaluation of this and similar community-based programs, particularly in understanding the impact on the health outcomes of the child. Finally, the hiring of community health workers and the evaluation of their role needs to be promoted by health-care, social service, governmental, and educational institutions. By creating jobs and supplying training, health-care institutions can assist with the welfare reform process and, in turn, provide services complementary to traditional care.

	Footnotes

 
Abbreviations: CAW = community asthma worker; HHPAP = Henry Horner Pediatric Asthma Program

Financial support was received for this project from the Northern Trust Company, Rush-Presbyterian-St. Luke's Medical Center, the Health of the Public (supported by the Robert Wood Johnson Foundation, Rockefeller Foundation, and Pew Charitable Trusts), and Astra, USA, Inc. Donations provided by DeVilbiss Healthcare, Invacare, Key Pharmaceuticals, the Boys and Girls Clubs of Chicago, the Chicago Housing Authority, and the Chicago Asthma Consortium.

	References

TOP Introduction Description of Program Program Achievements Challenges and Future Directions References

 

1. Marder, D, Targonski, P, Orris, P, et al (1992) Effects of racial and socioeconomic factors on asthma mortality in Chicago. Chest 101(suppl),426S-429S[Free Full Text]
2. Eckenfels E. The Rush Community Service Initiatives Program: a model to enhance community health through student faculty collaboration. In: Skelton WD, Osterweis M, eds. Promoting community health: the role of the academic health center. Association of Academic Health Centers, Washington, DC, 1993

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