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: Strengths and Challenges of the Program
Community Health Workers
The YES WE CAN asthma team addresses both the medical and psychosocial aspects of asthma that are characteristic within this sub population. The CHWs’ involvement in the clinic activities (orientation, education, home visits) brings them face to face with patient families early in the intervention. The CHWs come from the communities they serve, and they are trained in cultivating trust. Minority patients and their families identify with the CHWs who share the same ethnic heritage and language. This interaction between the CHWs and the families improves program credibility among those being served. The CHWs are the connectors between clinic staff and patients, serving as the clinicians’ eyes and ears. The CHWs learn what is going on with asthma management at the patient’s home (for example, whether the patient is not taking medications or the environmental conditions at home are deplorable), and they report this back to the team so these issues can be addressed and resolved. According to cofounder and director of the program, Vicki Legion, "The asthma team’s medical/social approach allows the intervention to walk with two legs. Medical care and social assistance must be married because even the best medical regimen will not work if families have social complications. Program effectiveness is greatly enhanced by the three member team approach." Dr. Antonia Sacchetti, Medical Director of the Mission Neighborhood Health Center, praises the work of the CHW on the asthma team. "The doctors here know that the program could not obtain the health outcomes it does without the CHW. The CHW is indispensable to this program."
The program is based on a proven model for asthma management
The YES WE CAN clinical care system that targets high-risk children delivers care through a multidisciplinary team, employs feedback loops and close care management, and promotes asthma self-management. It has proven to be successful in the chronic condition management model pioneered in Northern California by Kaiser Permanente. The YES WE CAN leadership enriched the newly adopted program with the introduction of the CHW into the team, and then applied this hybrid asthma care system to the neediest segment of the population, inner-city minority children. The YES WE CAN directors also incorporated recommendations and suggestions from KP/NC chronic condition management leaders as it launched the demonstration project. Subsequent health outcome data from YES WE CAN patients and their families who have completed the program over the years has further proven the effectiveness of this approach to asthma care.
Since 1997, rates of hospitalizations for asthma have fallen 21.1% and ED visits for asthma have fallen 48.8 % among KP patients on average among all eight KP/NC regions of the country (Testimony before the Subcommittee on Health of the House Committee on Ways and Means, March 18, 2004, by Dr. Francis J. Crosson, Executive Director, The Permanente Federation, Kaiser Permanente). This record suggests that the YES WE CAN program can be successfully replicated in other communities with similar positive results.
Regularity of case conferences
Holding asthma team case conferences regularly at the end of each clinic day, as initially projected, was a challenge that could not be overcome. The difficulty was finding the time when all three asthma team members could meet together at the end of clinic. Often the clinical case manager and the CHW met together to discuss the cases, but the clinician was not always present. At times, any one or more of the asthma team were faced with conflicting priories that prevented the case conference from occurring. The solution was to reduce the number of case conferences each week to one. These meetings are often held on Fridays at the end of the week or in the afternoon of the last clinic day of the week. During this one sitting, the asthma team reviews all the cases of patients who visited the clinic during the week so they can develop or revise care plans for each patient as needed.
Getting graduated families reconnected with their primary care providers
Some families do not understand that once their child’s asthma is under control, the family demonstrates it can manage the child’s asthma, and the child has graduated from YES WE CAN, they are to return to their primary care physicians for continuing asthma care and prescriptions. The YES WE CAN experience is such a positive one for some families that they want to continue receiving asthma care for the child at the clinic instead of returning to their primary care provider. When they need more asthma medications or consultation, they continue to call on the clinic. Some families have become quite attached to their CHW and continue to call on them for assistance. Weaning these families away from continued dependence on the YES WE CAN clinics and the CHWs is an ongoing challenge. Repeated explanations of this "graduation process" will help families better prepare for and accept the return to mainstream care.