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16 CAHQ Journal, Quarter 3, 2008 By: Regina Otero-Sabogal, PhD 1; Desiree Arretz, MD 2; Victoria Ngo, BS 2; Julie McKown, RCP, RRT, AE-C 2; Judy N. Li, DrPH, MBA 2; Russell Lee, PhD 2; Jeffrey Newman, MD, MPH 1, 3 This paper highlights the development, implementation, and evaluation of the HealthFirst pediatric asthma program at St. Luke’s Health Care Center in San Francisco. The objec- tive of this pilot program is to develop an alternative model of pediatric asthma self-management among economically disadvantaged, low-income, inner-city children using an integrated team-based approach with community health workers, licensed practitioners, and primary care physicians. Positive Impact of a Self-Management Program on Improving Asthma Symptoms Among Inner-City Children: St. Luke’s HealthFirst Center For Education and Prevention California Pacific Medical Center, St. Luke’s HealthFirst Center 2, Sutter Health Institute for Research and Education 3, and Institute for Health and Aging, University of California, San Francisco 3

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Page 1: Positive Impact of a Self-Management Program on …Self-Management Definition Self-Management Support is what health providers do to assist patients and their caregivers to become

16 CAHQ Journal, Quarter 3, 2008

By: Regina Otero-Sabogal, PhD 1; Desiree Arretz, MD 2; Victoria Ngo, BS 2; Julie McKown, RCP, RRT, AE-C 2; Judy N. Li, DrPH, MBA 2; Russell Lee, PhD 2; Jeffrey Newman, MD, MPH 1, 3

This paper highlights the development, implementation, and evaluation of the HealthFirst pediatric asthma program at St. Luke’s Health Care Center in San Francisco. The objec-tive of this pilot program is to develop an alternative model of pediatric asthma self-management among economically disadvantaged, low-income, inner-city children using an integrated team-based approach with community health workers, licensed practitioners, and primary care physicians.

Positive Impact of a Self-Management Program on Improving Asthma Symptoms Among Inner-City Children:St. Luke’s HealthFirst Center For Education and Prevention

California Pacific Medical Center, St. Luke’s HealthFirst Center 2, Sutter Health Institute for Research and Education 3, and Institute for Health and Aging, University of California, San Francisco 3

Page 2: Positive Impact of a Self-Management Program on …Self-Management Definition Self-Management Support is what health providers do to assist patients and their caregivers to become

CAHQ Journal, Quarter 3, 2008 17

This three-year pilot program is funded

by The Skirball Foundation and The

Atlantic Philanthropies.

Serious Health and Economic Consequences of Childhood Asthma

Asthma is the most common chronic

disease among children and the most

frequent cause of childhood hospi-

talization.1 This chronic respiratory

condition and inflammatory disease

of the airways have recurring episodic

symptoms of breathing difficulties -

wheezing, shortness of breath, and

coughing.2, 3 Asthma is a serious, grow-

ing public health concern with major

economic consequences.2-4 Severity of

asthma symptoms have been associated

with hospital admissions, mortality, as

well as developmental, emotional, and

behavioral problems5, 6 Many asthma

comorbidities such as activity restric-

tion, emergency visits, and missed

school days are preventable with ap-

propriate self-management strategies.7

Asthma can be controlled with minimal

symptoms and few disruptions in usual

daily activities.8

California Childhood AsthmaDespite major advances in asthma

control, many California children are

at increased risk of this fatal disease (see

Table 1). In fact, in California nearly

one in five students have asthma.6

California Has a High Asthma Prevalence Rates

In California, more than five million

individuals have been diagnosed with

asthma at any point in their lives, and

almost three million currently have

asthma.9 This significant disease is a

major concern for California children

- about 1.7 million California children

have been diagnosed with asthma at

some point in their lives, while 827,000

children currently have asthma.2 Results

from the 2001-2003 California Healthy

Kids Survey showed that the overall

lifetime adolescent asthma prevalence

was 18 % in California.6

Children of Ethnically Diverse Populations Have the Highest Asthma Prevalence Rate

Children from racial and ethnically

diverse populations are at higher risk

for asthma and related hospitalizations,

and their asthma is more severe than

White children.10 The prevalence of

childhood asthma has increased in the

last 2 decades in low-income, ethnically

diverse, and children living in inner

cities.7, 11 African American students

(26%) had the highest lifetime asthma

Table 1: California Childhood Asthma Facts

Characteristics California Asthma Facts in Children

Major Public Health

Concern

Asthma is a serious chronic illness among 11.3

percent California’s children*

Most Frequent Cause of

ED Visits

34% of children with daily and weekly asthma

symptoms had at least one emergency department

and urgent care visit in the previous year*

Most Frequent

Cause of Childhood

Hospitalization

In the Bay Area and California, asthma is the

diagnosis most often cited for children’s hospital

stays and accounts for roughly 9 percent of all

statewide hospital discharges involving children in

2006**

Leading Cause of

School Absenteeism in

Children

Asthma is the main cause of school absences in

California. About 28% of school-age children miss

at least one week of school*

High Prevalence Among

School-age Children

Despite advances in therapy, asthma remains a

disease that is not optimally controlled in many

Californians*

* Source: UCLA Center for Health Policy Research, California Health Interview

Survey, 2005

** Source: California Breathing, Environmental Health Investigations Branch,

California Department of

Public Health, 10/16/07. Available at: www.califiorniabreathing.org

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18 CAHQ Journal, Quarter 3, 2008

prevalence rates, followed by Whites

(20%), Native Americans (19%), Asian

and Pacific Islanders (16%) and Latinos

(14%).6 In 2003, the prevalence of Cali-

fornia pediatric asthma ranged from

13% for Mexican American students to

23% among Puerto Rican and Cu-

ban American Students, and between

11% among Korean American to 24%

among Filipino American students.12

Also, one-third of students had at least

one asthma symptom in the previous

year.6 Lifetime asthma prevalence rates

were higher among males than females.6

Economic Burden of AsthmaThe health and economic burden

of asthma is significant since there

are almost 500 asthma-related deaths,

36,000 hospital discharges, and 145,000

emergency department visits every year

in California.2 In 2005, about 659,000

persons suffered from asthma symp-

toms every day or week, and more than

475,000 visited an urgent care center

or emergency department because of

asthma.9 In 2005, the average charge for

an asthma hospitalization was $23,953

and the total costs of asthma hospital-

izations were $763 million in Califor-

nia.2 In the US, the direct and indirect

costs for health and lost of productivity

due to asthma are estimated at $19.7

billion annually.4

Childhood Asthma is a Leading Cause of School Absenteeism and Physical Inactivity

In 2005, asthma was responsible for

about 1.9 million missed days of school.

On average, California children with

asthma missed 2.6 days of school yearly

due to their asthma.9 Also, one out of

every three children had an episode

of asthma or an attack in the previous

year, 60% could not do physical activity

sometime in the previous year because

of their asthma, and 62% did not re-

ceive an asthma management plan from

their healthcare provider. 2 In addi-

tion, 28% of those with daily or weekly

symptoms, did not take daily asthma

medications.2

In spite of the high prevalence and

the negative health and economic

consequences of asthma, most of the

morbidity associated with asthma is

preventable and can be controlled

through self-management programs like

HealthFirst.7, 13

Lack of Primary Care Access Among San Francisco Inner-city Children

The city of San Francisco is experi-

encing continued growth in the portion

of the pediatric population who are un-

insured. The lack of access to primary

care that lead pediatric patients to have

poor asthma control and more frequent

respiratory complications creates a

burden on San Francisco’s public health

system and leads to over-utilization

of the city’s emergency rooms (ED).

Among the 58 California counties, San

Francisco ranks 4th highest in pediatric

asthma hospitalizations, highest for

Asian children, and second for Latino

children.14

Need for New Primary Care Delivery Models To Increase

Access in San FranciscoIn order to expand eligibility and

improve access for the uninsured and

under-insured pediatric population,

new primary care delivery models that

enhance access are essential to cost-

effectively manage asthma patients.

In San Francisco, the overall asthma

prevalence rate among children 0 to 14

years old is 13.8% with African Ameri-

can, low-income, uninsured children

showing the highest prevalence rates.12

A recent study of 230 hospitalized

children who were admitted for asthma

showed that most were poor, non-white,

and had public or no health insur-

ance.15 In addition, lack of continuing

primary care for asthma is associated

with increased levels of morbidity in

low-income children including im-

migrant children.16 African American

and Latino children are more likely to

receive episodic asthma treatment that

does not follow guidelines for care.17

An additional challenge to provide ef-

fective pediatric asthma care is the high

healthcare costs contrasted with low

reimbursement rates. For example, pe-

diatric visits to emergency departments

are high – nationally, one in every four

ED visits is a pediatric visit 18 which

means approximately 30 million ED

pediatric visits annually.19 This high ED

visit rate is very concerning due to low

reimbursement. While charges for pedi-

atric ED visits rise over time, payments

do not keep pace. A study comparing

charges and payments for outpatient

pediatric emergency visits across payer

groups in San Francisco showed that

reimbursements for outpatient ED visits

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CAHQ Journal, Quarter 3, 2008 19

in the pediatric population have de-

creased from the period of 1996 to 2003

in all payer groups: private, public such

as MediCal/State Children Insurance

Program (SCHIP), and the uninsured.

MediCal/SCHIP has consistently paid

less per visit than the privately insured

and the uninsured.20 Thus, there is an

urgent need to implement comprehen-

sive and cost-effective primary care

delivery solutions to improve healthcare

access and provide effective pediatric

asthma management care.

St. Luke’s Health Care CenterIn January, 2007, St. Luke’s Hospital

became the fourth campus of Califor-

nia Pacific Medical Center (CPMC),

which is a Sutter Health affiliate. St.

Luke’s has a 134-year history of serv-

ing those in need of health care in the

Mission and South of Market Districts

in San Francisco, CA. It has experi-

enced a dramatic shift in the payer mix

from insured to MediCal. St. Luke’s

has a keen interest in exploring in-

novative practices for caring for the

pediatric uninsured and underinsured

population with asthma. Asthma is

a preventable condition, therefore St.

Luke’s HealthFirst team is commit-

ted to improve asthma primary care

services and to reduce ED visits among

low-income children by implementing

an integrated team-approach interven-

tion that provides continuity of care,

cultural competent care, and parental

self-management.

HealthFirst Enhances Access to Pediatric Primary Care Services

In November 2006, CPMC launched

HealthFirst at the St. Luke’s Health

Care Center to expand eligibility and

improve access to the Mission and

South of Market area of San Francisco

mostly for the underinsured Medi-

Cal patient population. St. Luke’s

patients represent a wide racial, ethnic,

and linguistic diversity. According to

Census 2005 data, 46% of the residents

within the communities served by the

HealthFirst can be categorized as hav-

ing limited English proficiency (LEP)

and speak languages other than English

at home; 42% are Hispanics, 16% are

Asians, 16% are Blacks, 23% Whites,

and 3% Other. About 11% are below

the federal poverty level.

Integrated Team-Based Approach

The Integrated Team-Based Ap-

proach pilot program aims at improv-

ing how primary care is delivered in a

more cost-efficient manner to manage

patients with chronic diseases by pro-

viding timely access to a primary care

physician, appropriate utilization of

emergency room, improved physician-

patient communication, enhanced

patient education, better coordination

of healthcare services, and increased

healthcare access by providing cultur-

ally and linguistically appropriate

healthcare services.

The HealthFirst pilot program

involves moving from a Provider-

Focused Care Model into an Integrated

Team-Based Approach. The key reason

to adopt this strategy is explained by

a HealthFirst consultant Dr. Boden-

heimer “As the 21st century unfolds,

primary care is endangered. Strain is

evident among primary care physi-

cians. Primary care in the United States

is showing increasing signs of strain

because of heightened expectations for

performance and shifting demographic

and health care trends. Effectively re-

sponding to these problems will require

fundamental redesign of systems for de-

The HealthFirst multilingual, multicultural team includes primary care physicians

working closely with a nurse practitioner, a licensed respiratory therapist, a social

worker, a program evaluator, administrators, and community health workers trained

as asthma educators.

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20 CAHQ Journal, Quarter 3, 2008

livering primary care.”21 This integrated

teamlet approach expands the limited

15-minutes physician visit using the

support of community health workers

who act as health coaches and provide

regular follow-up..21

The core of St. Luke’s HealthFirst

approach includes:

1. System-Level Pediatric Primary Care Redesign

To provide quality pediatric services,

HealthFirst is implementing organiza-

tional changes at multiple levels:

Re-design Pediatric Primary •

Care Practices.

Pediatric practices have been re-

designed to increase capacity. Two

pediatric practices have been con-

solidated into one. Improvements

have been made in patient flow,

scheduling, and patient referrals.

Build Capacity and Improve •

Resources.

Improvements in decision support

to provide quality of care and to

manage the patient population

have been made.

Establish Efficient Service Deliv- •

ery Systems.

HealthFirst has made improve-

ments on patients’ access to services

at the time when it is necessary.

Community health workers liber-

ate physician time to do what they

do best.

Adopt New Physicians, Midlevel •

Educator, Community Health

Workers, and Patients Roles.

Physicians work on teams. Com-

munity health workers and licensed

non-physician clinical staff monitor

clinical outcomes and empower pa-

tients with self-management skills.

Patients learn problem-solving

skills to take better control of their

disease.

Incorporate Clinical Outcome •

Measurements to Evaluate

Progress.

Closely monitoring patient

progress.

2. Culturally Tailored Intervention and Team Interdependency.

The HealthFirst multilingual, mul-

ticultural team includes primary care

physicians working closely with a nurse

practitioner, a licensed respiratory ther-

apist, a social worker, a program evalu-

ator, and community health workers

trained as asthma educators. The team

delivers a culturally tailored interven-

tion to improve both patients’ self-man-

agement and caregivers’ management

of their children asthma symptoms

and quality of life. The pediatrician

initially introduces the team-based

care approach to the patient during an

initial asthma visit and recommends a

medical plan, which includes follow-up

with the HealthFirst team. Commu-

nity health workers develop and foster

a trusting relationship with the patient

and his family. After a comprehensive

evaluation, which includes environment

assessment, psychosocial assessment,

and lung function assessment, the com-

munity health workers and the respira-

tory therapist work with the patient to

develop an action plan to care for his or

her asthma. Education on asthma and

use of medical devices are often rein-

forced at every visit. All team members

have access to the patients’ medical

records to work with the patient on a

treatment plan, with the nurse practi-

tioner available to ensure clinical qual-

ity and make any adjustments to the

medications. The social worker provides

referral and counseling on psychosocial

issues. Community health workers

conduct patient follow-up by telephone

and in-person visits. 21 The community

health worker is the bridge between

all members of the team and facilitates

communication among the providers

and patient’s family. The intensity of

follow-up varies by patient’s needs.

A similar team-approach model was

used successfully with 7 community

clinics with approximately 3,000 low-

income children. At 24 months follow-

up in the longitudinal sample, fewer

patients reported acute visits, emergen-

cy department visits, hospitalizations,

frequent daytime and nighttime asthma

symptoms compared with baseline.22

3. Self-Management Support Services

HealthFirst pilot program is based

on the assumption that teaching

patients and caregivers to self-manage

their chronic condition improves their

clinical and functional outcomes, sat-

isfaction with care, and reduce hospi-

talizations and visits to the emergency

department.7, 23-26

Table 2 shows key concepts incorpo-

rated in the HealthFirst self-manage-

ment program.

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CAHQ Journal, Quarter 3, 2008 21

HealthFirst Community Health Workers Role on Self-Management Support

HealthFirst community health work-

ers aim to gain patients’ trust and use a

self-management approach to empower

the child and caregiver to control the

asthma symptoms. During the Health-

First visits, the community health

worker works collaboratively with the

caregiver to set the agenda; “close the

loop” to verify the patient and parents

understanding of clinician advice;

encourage parents to make decisions

about environmental control; use of

devices and medications; and set goals

to assist with lifestyle changes.

Community health workers have an

important and unique role in teach-

ing parental self-management when

working in close collaboration with

pediatricians and other clinicians. They

also serve to unify the team through the

facilitation of communication within

the team, which includes the patient

and his/her caregiver. At HealthFirst,

community health workers improve

patients’ activation and confidence to

manage their chronic condition. In

turn, more activated patients have bet-

ter health outcomes and are more satis-

fied with services. This important role

requires intensive training to develop

new competencies including knowledge

of asthma clinical protocols, medica-

tion reconciliation, asthma devices and

patient self-management techniques.

Self-management education comple-

ments traditional patient education

in supporting patients to live the

best possible quality of life with their

chronic condition. Whereas traditional

patient education offers information

Table 2: Definition and Characteristics of Self-Management Support

Self-Management Definition

Self-Management Support is what health providers do to assist patients and

their caregivers to become active participants in their own care. It is a patient-

centered approach to empower the patients and their caregivers to have a

central role in managing their own chronic illness.

Self-Management Characteristics

Support patients and their caregivers to set realistic goals, define specific

actions, and reach a mutual agreement in the steps to be taken to reach their

goals

Train patients and caregivers intensively in specific disease skills

Provide informational, emotional support, and problem-solving skills to increase

self-confidence, self-efficacy, and self-esteem to manage their chronic illness

Interact with patients and their families in a positive, respectful, and linguistically

and culturally appropriate manner

Provide ongoing follow-up

Encourage healthy behavior change

Assist patients and caregivers with psychosocial issues

HealthFirst community health workers facilitate communication and coordination

among care team members, and empower patients and caregivers with problem-solving,

asthma self-management skills. In their expanded role, they liberate physician time to

do what they do best.

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22 CAHQ Journal, Quarter 3, 2008

and technical skills, self-management

education teaches problem-solving skills

to improve patient and caregiver’s confi-

dence.23 Evidence from a meta-analyses

of controlled clinical trials suggests

that: (1) Programs teaching self-man-

agement skills are more effective than

information-only patient education

in improving clinical outcomes; (2)

Educational programs for the self-

management of asthma in children and

adolescents reduce absenteeism from

school, number of days with restricted

activities, number of visits to the emer-

gency department and possible number

of disturbed nights.7, 13 Using these prin-

ciples, HealthFirst focused on assisting

low-income patients in self-managing

their condition using community health

workers who teach problem-solving and

self-efficacy skills (see Table 3).

HealthFirst Pediatric Asthma Program Components

The HealthFirst Integrated-

Care Model has several interrelated

components:

1. Patient Referral and Needs

Assessment. Two primary care

pediatricians and two mid-level pro-

viders refer patients to HealthFirst.

The multidisciplinary team conducts

a comprehensive initial and quarter-

ly assessment of individual patients.

The assessment includes educational,

psychosocial and clinical factors;

access barriers; social support;

co-morbid conditions, and needed

referrals.

2. Action Plan and Goal Setting. The

community health workers and

the respiratory therapist work with

patients and caregivers to facilitate

goal settings and implement an

action plan after every visit. Both

“close the loop” teaching patients

and caregivers how to use medicines

and devices properly, how to im-

prove environmental conditions and

work on an action plan. The care-

giver and patient learn what control

of asthma symptoms is. They learn

that it is not normal to have the

child coughing all the time and to

wake-up at night. When caregivers

and patients see peak flow changes

after using the medication correctly,

they feel more confident to manage

the symptoms.

3. Patient Follow-up. To monitor

patient improvement, community

health workers meet with caregivers

and patients as needed and conduct

follow-up phone calls. The number

of follow-up phone calls varies by

patient needs. Patients are seen every

three months for follow-up. Patients

with co-morbid conditions are seen

more frequently.

4. Inter-Collaborative Program

to Improve Access. HealthFirst

works in partnership with other

St. Luke’s programs and services

such as Respiratory Therapy, Social

Work, and the Diabetes Center. As

HealthFirst enrolls more patients,

it is expected that the St. Luke’s

Health Care Center will improve

access for other patients needing to

schedule visits.

5. Program Evaluation. The team uses

evidence-based clinical performance

measures collected at every visit and

utilization indicators to monitor

patients’ progress through a registry.

Table 3. HealthFirst Community Health Worker Expanded Competencies

Expanded Role for HealthFirst Community Health Workers

Work with physician and other

certified clinical staff as a team

member

Communicate with patient in a

culturally competent way

In depth knowledge of chronic

disease management and treatment

Work with patient as partner on

setting the agenda at each encounter

Use motivational interviewing

techniques to empower patient to

change

Knowledge of learning principles and

techniques to work with patient on

action plans

Use “closing the loop” technique

to verify patients and parents

understanding of treatment plan

Monitor patient progress using

registries or a database

Adapting information, educational

materials to patient literacy level

Attitude change from educating

to teaching patients’ new skills to

improve confidence

Teach problem-solving asthma

specific skills

Support self-confidence and self-

efficacy in asthma management

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CAHQ Journal, Quarter 3, 2008 23

HealthFirst has a research compo-

nent to assess the impact of the new

primary care model on patients’

clinical and utilization outcomes.

6. Expansion to Other Health

Care Center Practices. St. Luke’s

Health Care Center is building on

HealthFirst’s first year evaluation

findings to continue implementing

an integrated team-based approach

beyond pediatrics to improve the

quality of healthcare delivery at

reduced costs. This process involves

not only managing patients with

asthma and other chronic dis-

eases, but requires a re-design of

the St. Luke’s Health Care Center

organization.

Methods

SampleThese preliminary results are based

on 85 pediatric asthma patients (Age

range: 0 - 16 years old, average age:

7 years old) enrolled in HealthFirst

between January and November 2007.

Sixty-five percent the pediatric asthma

patients are Spanish-speaking compared

to 35% who are English-speaking. Ex-

posure to second-hand smoke and lim-

ited control of environmental asthma

triggers is critical risk factors among

HealthFirst pediatric patients.

Cohort Baseline—Follow-up Comparison

We compared the clinical outcomes

and patient activation scores at base-

line with follow-up. Analyses include

comparison of proportions and averages

of clinical measures over time. These

analyses are based on data from two

measure periods: Baseline Period -

January to April 2007 and Follow-up

Period - September to November 2007.

Statistical analyses were performed us-

ing the SPSS statistical program.

Clinical OutcomesTwo clinical indicators to measure

improvement among the HealthFirst

pediatric asthma patients were number

of nights awakened in last four weeks

(night-time coughing and wheezing)

and daytime symptoms in the last week

(daytime coughing, wheezing, shortness

of breath, and chest tightness).

Self-Management OutcomeA Patient Activation Measure (PAM)

is used to measure caregivers’ degree of

confidence and skills to manage their

children asthma conditions. PAM was

adapted from the measure developed

by Judith Hibbard and colleagues at

the University of Oregon.27 The Patient

Activation Measure (PAM) assesses

people’s knowledge, confidence and

skills for self-management. The short

version of the measure has 13 items

pertaining to four domains:

1. Believing the patient role is

important;

2. Having the confidence and knowl-

edge necessary to take action;

3. Taking action to maintain, and

4. Improving one’s health staying the

course even under stress.

The PAM scale has been extensively

tested and shown to be a valid, highly

reliable instrument with good psycho-

metric properties. It was translated to

Spanish and pretested with the Latino,

low-literacy patient population. The

measure produces activation scores

ranging from 0 to 100 (less activation

to more activation). The PAM measure

was applied in-person by a community

health worker. The scale consists of a

series of statements with five possible

response categories: Strongly agree,

Agree, Disagree, Strongly disagree, Not

applicable.

ResultsAfter the first year of operation,

the HealthFirst program shows an

encouraging impact on the clinical

outcomes of a cohort of 85 pediatric

patients who were seen between January

and November 2007. These patients

decreased the daytime and nighttime

asthma symptoms, and their caregivers

reported improvement in the degree of

self-confidence to control their children’

asthma symptoms.

1. Nights Awakened in the Previous Four Weeks Decreased.Figure 1 shows the effectiveness of

HealthFirst to control the number

of nights awakened in the previous 4

weeks. Overall, the average number of

nights awakened decreased significantly

from baseline 5.60 to follow-up 2.22

(t=3.18, df: 84, p<.002).

2. Daytime Asthma Symptoms in the Previous Week Decreased.Figure 2 shows the results of the ef-

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24 CAHQ Journal, Quarter 3, 2008

fectiveness of the HealthFirst program

to control daytime asthma symptoms.

Overall, pediatric asthma patients de-

creased the number of daytime asthma

symptoms from uncontrolled (e.g., “all

the time or three times a week”) to

controlled (e.g., “no daytime symptoms

or one or twice a week”).

The proportion of pediatric asthma

patients with well-controlled daytime

asthma symptoms increased from

baseline to follow-up. About 60.5 %

had daily asthma symptoms under

control at first measurement period and

increased to 84.7% at follow-up

3. Self-Management of Asthma SymptomsThe perception of caregivers about

their children’s control of asthma

symptoms measured by a Patient Acti-

vation scale improved from baseline to

follow-up.

As Figure 3 shows the average

Patient Activation score (PAM) im-

proved slightly from moderate control

(PAM=57.8) at baseline to more active

control (PAM=64.4) at follow-up.

DiscussionThe St. Luke’s HealthFirst team-

based approach is improving Latino,

African American, and White low-

income children daytime and night-

time asthma symptoms as well as their

caregivers’ degree of confidence and

skills to manage their children asthma

conditions. These results provide sup-

port for the application of an integrated

team-based intervention approach in

inner-city primary care settings. These

findings also support the need of work-

ing with community health workers on

an expanded role—collaborating as a

team member with other non-medical

providers to improve caregiver and

patient’s confidence and skills to control

their home environmental triggers, ad-

here to medications, and use correctly

their medication devices with the objec-

tive to decrease emergency department

utilization and reduce healthcare costs.

Asthma is a preventable chronic care

condition that requires a very close

partnership between the child, care-

giver, and their health providers. To

achieve this objective, HealthFirst pro-

vides continuity of care and self-man-

agement skill training through periodic

visits in which patients and caregivers

obtain feedback about their adherence

to a realistic action plan to control their

asthma symptoms. When a patient

and his or her caregiver use effective

self-management skills understanding

their disease and role in taking control

of their condition, they report improved

patient satisfaction, activation, and have

better patient no-show rates (e.g. about

15% vs. about 30% for referrals to the

St. Luke’s Respiratory Department).

In contrast, before HealthFirst was

implemented, under the provider-

focused approach, a pediatrician was ex-

pected to fulfill multiple roles and could

not provide frequent check-ups. The

time of the respiratory therapist was

divided among all asthma patients at

the hospital. There was no staff to help

with scheduling or documentation and

the respiratory therapist was solely re-

sponsible for follow-up. Patients did not

understand the chronic nature of the

disease. Therefore, asthma symptoms

could not be treated promptly, patients

got worse and ended up utilizing the

Emergency Room to be seen promptly.

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CAHQ Journal, Quarter 3, 2008 25

Non-show rates were about 30% since

follow-up was very sporadic which

made patients feel frustrated because

the limited access to appointments

when they needed. As HealthFirst con-

tinues, it is expected to improve access

to follow-up appointments and to enroll

more patients in need.

Lessons LearnedWe learned key lessons during the

first year of implementing the Health-

First self-management program for

low-income pediatric patients and their

caregivers:

Support for Goal Setting and

Action Planning. Self-management

action plans are a critical element in

asthma care.28 HealthFirst’s care team

provides extra support to establish a

very simple action plan. Patients and

their caregivers focus on specific activi-

ties to follow (e.g., what, how much,

when, how often) and their level of

confidence to implement the desired ac-

tivity. Community health workers used

motivational interviewing strategies to

help patients and caregivers to set goals

and choose activities to reach their

goals. Focus on improving self-efficacy

on disease-specific skills and providing

timely follow-up is central to goal set-

tings and action plans. Similar findings

were observed in a study that produced

major improvements in asthma-related

care processes and clinical outcomes

after the implementation of regular

asthma action plan review along with

assessment of quality of care and con-

fidence in self-management, and docu-

mentation of guideline-based asthma

quality indicators.22 Parents’ unique

asthma concerns need to be integrated

in refining the child’s asthma action

plan.29 Similarly, HealthFirst results are

in the same direction of another study

that found that after the introduction

of an asthma action plan, daytime and

nighttime symptoms decreased while

caregivers reported positive attitudes

about the usefulness of the action plan

knowing what to do about it.30

Integrated Team-based Approach

With Efficient Asthma Care Pro-

cesses. A central feature of the Health-

First self-management program is the

expansion of roles among the care team

using a collaborative care model.21, 23

An interdependent team composed of

primary care physicians, a nurse prac-

titioner, licensed respiratory therapist,

a social worker, and community health

workers focus on conducting an assess-

ment and treatment plan customized to

the child and family needs.31 This new

care team partnership require that pa-

tients and caregivers have an active role

in managing their own disease and are

encouraged to set obtainable goals and

follow a specific treatment action plan.32

The results of an integrated team-based

approach produce better care coor-

dination, increased communication,

better patient/family satisfaction, and

reduction of asthma symptoms. Also,

as found in other studies, having a

continuing primary care for asthma

has been associated with lower levels

of morbidity in low-income minority

children.17 In addition, as other studies

also found, using community health

workers and a team-based approach

along with effective redesign of pedi-

atric asthma processes, have produced

major improvements in asthma-related

health outcomes among low-income,

multiethnic children.22

Tailored Linguistically, Culturally,

and Health Literacy Intervention to

Improve Asthma Health Services Ac-

cess. A central feature of the Health-

First self-management program is the

improvement of access to linguistically

and culturally appropriate asthma

services. Bicultural and bilingual care

team members explain condition-

specific information in plain language,

using concrete examples, and provid-

ing culturally appropriate tools and

educational materials customized to the

patient and caregiver literacy level.33, 34

Community Health Workers Ex-

pand Physicians Time and Quality of

Care. Community health workers ad-

vocate for patients and their caregivers

and facilitate communication between

the primary care provider and other

care team members. Since many pa-

tients and their caregivers do not fully

understand how to control their asthma

and what treatments are available to

them,31 community health workers

teach disease-specific self-management

skills as well as motivate patients to

improve their problem-solving skills.23

Community health workers conduct

patient follow-up by telephone and

in-person visits using the “closing-the-

loop” technique to check for under-

standing of action plans and treatment

options. HealthFirst is committed to

train community health workers to

work independently under the supervi-

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26 CAHQ Journal, Quarter 3, 2008

sion of a physician assistant to provide

support, health education, and case

management services to patients and

their families using an empowerment

approach in coordination with health

care providers and systems.

Monitoring Performance Measures

Provide Guidance for Improvement

of Patient Self-Management. Data

collection and analysis are major chal-

lenges in busy primary care clinics since

these activities often demand extra

time, effort, and precision. HealthFirst

has designed an electronic tracking

system to collect and monitor asthma

quality indicators including a patient

activation measure. The close monitor-

ing of quality indicators via an elec-

tronic population management system

allows team members to follow-up

patients closely and better manage

resources. Since data entry and database

maintenance are critical components of

obtaining valid data, careful selection

of efficient quality measures and staff

training in documentation and data

entry is highly recommended.

HealthFirst is one of the few exam-

ples nationally of a healthcare facility

entirely focused on assisting patients in

self-managing their chronic conditions

and conducting research under “real

world” conditions to assess the impact

of the new primary care model on pa-

tients’ clinical and utilization outcome.7,

22, 35, 36 Comparable demonstration

self-management asthma multifaceted

programs which have used community

healthcare workers, quality improve-

ment clinical process redesign, and

asthma action plans reviews, have docu-

mented improvements in confidence in

asthma self-management, better quality

of life, and reduction in emergency de-

partment visits and hospitalizations.22,

35, 37, 38 HealthFirst preliminary results

are in the same direction of systematic

reviews that show that effective asthma

self-management programs in children

and adolescents improve lung func-

tion, physical activities, and feelings of

self-control, along with a reduction of

asthma symptoms, hospitalizations, and

absenteeism.13, 36 Lessons learned from

the design and implementation of the

HealthFirst model are used to expand

other primary care practices at St.

Luke’s Health Care Center.

Our preliminary results have limita-

tions. They are based on self-report

from a small cohort of patients. We are

aware that the successful delivery of

HealthFirst self-management services

and patients adherence to self-manage-

ment action plans depends not only on

the provision of HealthFirst services,

but on patient’s individual, social and

contextual factors including cultural

beliefs, perceived barriers, experience

with healthcare providers, education,

literacy, insurance, race, and age among

other factors. We plan to carefully

monitoring these factors to guide deci-

sions regarding the type of patient who

would benefit by HealthFirst.

Besides these challenges, we are

convinced that a successful Integrated

Team-Based Approach for pediatric

patients and their caregivers such as

HealthFirst must have a multi-faceted

approach to be successful: promote

an integrated team-based approach,

expand the role of community health

workers to liberate physician time to do

what they do best, empower patients

and their caregivers to play a central

role to in managing their disease, sup-

port and follow-up patients and their

caregivers in setting obtainable goals

and action plans, create a culture of col-

laboration and mutual support among

healthcare providers and patients/

caregivers, promote linguistically and

culturally appropriate delivery services,

track clinical outcome performance

measures to monitor progress, and

promote an organizational commitment

and a culture of continuous quality and

organizational improvement.

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AuthorsDesiree Arretz is HealthFirst’s Medi-

cal Director. She has a medical degree

from Case Western Reserve University

and completed her residency in Internal

Medicine at the University of Califor-

nia, Davis Medical Center. From 1988

– 1989, she developed an educational

program for a Latino AIDS community

organization, Salud, Inc., in Washing-

ton, D.C. While in medical school, she

worked with the Federation of Com-

munity Planning surveying the health

attitudes of Puerto Ricans in Cleveland,

Ohio. At UC Davis Medical Center,

she studied the prevalence of PPD

positivity among migrant workers in

Yolo County. Dr. Arretz has worked for

the past twelve years as a primary care

physician in the San Francisco Mission

District on underserved populations.

E-mail: [email protected]

Regina Otero-Sabogal, PhD is a

bicultural psychologist and an Adjunct

Professor at the University of California

at San Francisco, Institute for Health

& Aging, Department of Behavioral

Sciences. She is the program evaluator

and healthcare consultant for Health-

First. She has worked on multiple

health promotion, disease prevention

and health care quality improvement

program interventions in multi-ethnic

communities for more than 25 years.

Her research focus includes developing,

implementing, and evaluating inter-

ventions in chronic disease, smoking,

sexually-transmitted diseases, and can-

cer screening for low-income multieth-

nic populations; identifying predictors

of cancer screening within the managed

care environment and community-

based clinics. As quality improvement

consultant for SutterHealth Institute

of Research and Education, her work

focuses on improving language access

and cultural competent services to

limited language proficient multiethnic

patients. Her studies on hospitals and

community clinics focus on re-design-

ing healthcare system primary care

practices to improve access and cultural

competence services. She is the lead-

ing author of numerous peer-reviewed

publications and collaborates with

international, state, and local research,

healthcare service agencies, and com-

munity organizations.

E-mail: regina.otero-sabogal@ucsf.

edu

Judy N. Li, DrPH, MBA is a health-

care strategist committed to improving

quality and access for the underserved.

Currently, she is the Chief Administra-

tive Officer of St. Luke’s, with overall

responsibility for the operations of the

newest campus of California Pacific

Medical Center (CPMC). Previously,

she was the Director of Strategy and

Program Development at CPMC,

where she developed initiatives aimed

at the revitalization of St. Luke’s

and integration into CPMC. Dr. Li

worked extensively in the area of health

informatics, research and program

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CAHQ Journal, Quarter 3, 2008 29

design. She implemented a physi-

cian connectivity system to improve

outpatient services at Brown & Toland

and co-founded a startup, Consumer

Health Interactive, to develop Web-

based applications and award-winning

consumer health content. Dr. Li also

conducted quality research on the

impact of remote monitoring technolo-

gies and on the potential of electronic

medical records to improve disease

management. She serves as a consultant

to the Moore Foundation’s Integrated

Nursing Leadership Program to create

nursing leaders and demonstrable qual-

ity improvements in Bay Area hospitals.

Outside of healthcare, Dr. Li served as a

legislative aide to U.S. Senator Dianne

Feinstein in Washington D.C. and led

program and business development

efforts for the Policy Division of SRI

International. Dr. Li holds Bachelor’s

degree from New York University, a

Master of Business Administration and

Doctor of Public Health from the Uni-

versity of California at Berkeley.

E-mail: [email protected]

Julie McKown, RCP, RRT, AE-C is

a Respiratory Therapist and coordinator

of the St. Luke’s Hospital Pulmonary

Education Program. At HealthFirst, she

provides asthma education and training

to the community health workers and

partners with them and the primary

care physicians by evaluating, assisting

with disease management, and provid-

ing diagnostic testing to their patients.

Ms. McKown received her training

from the Respiratory Therapy Program

of Skyline College. As a therapist, she

has experience in critical care, adult and

pediatric care, and pulmonary function

and is a nationally certified asthma edu-

cator. She has been a past co-chair for

the San Francisco Asthma Task Force,

past board member of the Bayview

Hunters Point Health and Environmen-

tal Resource Center, and is a current

member of the board of the Asthma

Resource Center of San Francisco, Inc.

E-mail: [email protected]

Jeffrey Newman MD MPH is Direc-

tor, Sutter Health Institute for Research

& Education, and Adjunct Professor,

Institute for Health & Aging, Universi-

ty of California, and San Francisco. An

internist and health services researcher,

he previously studied quality of care

and medical information systems at the

CDC, the San Francisco Department

of Public Health, and the Medicare

Quality Improvement Organization for

California.

E-mail: [email protected]

Russell D. Lee, PhD is the Health-

First Program Manager. Besides his

administrative responsibilities in devel-

oping the HealthFirst pilot program,

he is part of the management team

involved in restructuring the delivery

of primary care services at St. Luke’s

Health Care Center. For the past 15

years, he has worked as the opera-

tions manager in a hospital-centered

outpatient specialty clinic, a senior

analyst in surgical services at St. Francis

Memorial Hospital in San Francisco,

and a business development manager

at California Pacific Medical Center

in San Francisco. Prior to health care,

Dr. Lee worked over 10 years for two

major ocean container carriers - Maersk

Line and American President Lines - in

market research and logistics. His forte

is in applying logistics planning and

other decision support tools to optimize

outpatient clinic scheduling, patient

flow, and operations. He received his

doctorate in Sociology from Harvard

University.

E-mail: [email protected]

Victoria Ngo, B S. has helped de-

velop this program as a health coach

at CPMC HealthFirst Center since

its inception. She was in charge of

HealthFirst data management and

trained community health workers. A

tri-lingual, San Francisco native, she

is passionate about improving health-

care access for the underinsured and

underserved population of her commu-

nity. She received her bachelor degree

in Molecular and Cell Biology at the

University of California, Berkeley. She

strives to bring innovation to the evolv-

ing realm of healthcare.

E-mail: [email protected]