Inner City Asthma

Implemented in El Rio Santa Cruz Community Health Center, Tucson, Arizona by MAS Consultants Inc., P.O. Box 5130 Aiken, South Carolina 29804.

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.

Inner City Asthma: Description of Replicated Program

In early 2001, 23 locations around the country launched the Inner-City Asthma Intervention (ICAI), a 4-year program based on the NCICAS phase II study. The ICAI project is directed toward health organizations that treat low-income inner-city children, particularly those enrolled in Medicaid or the State Children’s Health Insurance Plan. The project objective is to create asthma patient management programs where none exist, rather than to replace existing programs. Every site has an in-kind project manager responsible for the conduct of the intervention. The project manager hires, trains, and supervises the project staff; ensures adequate enrollment in the program; ensures the intervention follows the protocol; and oversees the program outcome according to evaluation data.

The intervention site must employ an AC (a master’s-level social worker). The AC tailors the intervention to the needs of the individual children, works closely with children’s families over the year, and helps the families address a wide variety of problems related to their children’s asthma. The AC at each intervention unit (a site may have two or more ACs, each responsible for a unit) is expected to maintain a caseload of approximately 80 families. A project support person schedules appointments and maintains calendars, follows up on missed appointments, provides child care for families during family sessions, and maintains the records.

The El Rio Santa Cruz Community Health Center (El Rio) in Tucson, Arizona, one of the largest volume inner-city clinics in the country, was selected for this case study. In 1998, the Center had 187,000 visits to its facilities, with 45,000 users accessing health care. An estimated 21,000 children and adolescents receive primary care at El Rio, including about 2,100 children with asthma The Center has 47 physicians, including 12 pediatricians and 12 family practice physicians who care for children with asthma. The clinic includes a full-service laboratory, radiology and pharmacy services, and an educational training facility. The Center has drivers and a transportation fleet to transfer patients to and from their appointments within the Tucson area.

The population of Tucson and surrounding Pima County is 1.2 million. The asthma death rate of 3.2 per 100,000 in Pima and Cochese counties is the highest in Arizona and 22nd highest in the nation. El Rio serves a population that is 55% Hispanic and 24% Native American Indian; 5-10% are monolingual Spanish. Some of the key economic and demographic indicators of the El Rio service area, provided in the El Rio application for the ICAI grant, are:

• Persons living in poverty, 1989: 37.1%
• Rate of unemployment, 1990: 12.9%
• Adults with less than a high school education, 1990: 21.3%
• Linguistic isolation, 1990: 12.4%
• Median household income, 1989: $15,941

Dr. Uwe Manthei and Dr. Paul Enright are joint directors of the El Rio ICAI program. Dr. Manthei is a practicing allergist and clinical professor of pediatrics (Allergy/Immunology Section) at the University of Arizona. Dr. Enright is a pulmonologist involved in clinical research at the University of Arizona. These men have collaborated for several years promoting asthma education in southern Arizona and they worked together in the asthma clinic at the Respiratory Sciences Center in Tucson.

In addition to a full-time AC, the program employs a part-time Mexico-born bilingual respiratory therapist (RT). This added language resource is essential because so many Mexico-born Tucson area parents of children in the program do not speak English. The RT works in the clinic treatment room where sick children with asthma are identified and can be readily referred to the program. During office consultation, the RT communicates with Spanish-speaking parents and the AC communicates with the children, virtually all of whom speak English. The RT also is a trained instructor. With two instructors, the adult and children’s group sessions are taught in parallel rather than in series. The bilingual RT teaches the parents’ sessions, and the AC leads the children’s sessions.

Goals of the Replicated Program

The El Rio site adheres to the overall ICAI objective to decrease symptom days in inner-city children with asthma and thereby improve their quality of life and decrease unscheduled medical-care visits and hospitalizations. Supporting goals stated by the program managers and the staff include increasing children’s physical activities and keeping them in school. The program also empowers parents to manage their children’s asthma effectively and helps them acquire the assets and resources needed to manage the disease.

Goals that apply directly applicable to the family are as follows:

• Determine the child’s asthma triggers and take action to prevent exposure to them.
• Obtain and follow a written medicine plan from the doctor.
• Use appropriate asthma medications.
• Develop a partnership with the child’s doctor.
• Learn to use appropriate tools (spacer, peak flow meter, asthma log) to help manage the child’s asthma.
• Coordinate the child’s asthma care with his/her school.

Recruitment and Characteristics of the Target Population

Most of the children in the program are patients at the El Rio Health Clinic. In most instances, a parent brings his/her child with asthma to the clinic when the child is sick. A pediatrician examines the child and may refer the family to the asthma program, based on the child’s asthma severity and the family’s need for education and additional assistance. The ICAI program office is located in the El Rio pediatric clinic. The parent of a sick child is concerned about helping the child at this time and is usually interested in the asthma program. The AC acquaints herself with the family and schedules the intake appointment as soon as the child is expected to recover from the exacerbation, usually within the following week or two. A few children are referred to the asthma program from other medical locations within the city.

All children in the El Rio ICAI program are 6-12 years of age. They are eligible for Medicaid or state health care assistance. About 74% of the children are Hispanic, 15% are Yaqui Indian, and 11% are white or African American. Most come from medically underserved areas in the Tucson area. About 45% live in homes where someone smokes.