MCH Student:

Caitlin Grow

Date of Defense:

October 5, 2018

Abstract:

Introduction

Asthma is a chronic pulmonary disease affecting more than 20 million Americans, including 7.1 million children.^{1, 2} Children with asthma experience reduced quality of life and their symptoms contribute to missed school days.² Asthma is responsible for nearly 500,000 hospitalizations, 1.9 million emergency department (ED) visits, and more than 4,000 deaths annually.³ Asthma is an expensive chronic condition costing approximately $16.1 billion annually, including health care expenses (~$11.5 billion) and indirect costs including missed school and work days.³ Decreasing hospital and ED visits will reduce the total cost of asthma, representing a shift in care delivered, resulting in patients’ having better control of their asthma.

Though asthma affects nearly 7.1 million children, there are striking disparities among demographic and socioeconomic groups.⁴ African American children are 2.5 times more likely than their white counterparts to be hospitalized for their asthma.^{1, 2} Additionally, 17% of African American children had asthma compared with 8% of white and Hispanic children.² Moreover, African American and Hispanic children have a tendency to be diagnosed with more severe asthma while also having lower utilization of preventative medication than white children, even after adjusting for socioeconomic differences.⁴ Furthermore, in 2009 children who resided in low-income households (14%) experienced the burden of asthma at a higher incidence than those who reside in middle or upper income households (8%).²

 Minneapolis and Greater Hennepin County in Minnesota have some of the most striking disparities in asthma rates. Data analyzed from HCMC found that males make up 58% of asthma cases. The data also revealed that the top six cities with the highest percent of asthma cases included Minneapolis (49%), Brooklyn Park (~9%), Richfield (~6%), Brooklyn Center (~5%), Saint Paul (~5%), and Bloomington at (~4%). Furthermore, it was found those ages 5-14 make up 77% of all asthma cases. When assessing race in this dataset, African American children were five times more likely and Hispanic children were four times more likely to have asthma than their white counterparts. This analysis provides sufficient insight into those affected by asthma and reinforces the need for an intervention in this area to create better-managed asthma in this pediatric population.

 Experience

This field experience was located at Hennepin Healthcare – MVNA, within the Family Health section. MVNA was contacted by the Minnesota Department of Health (MDH) and asked to implement a Pediatric Asthma Home Visiting Program to improve pediatric asthma management in the community. The program provides four to six educational visits over a span of four months. MDH noted that many cases of uncontrolled asthma were found in North Minneapolis and Greater Hennepin County. Geographically these areas are comprised of low-income minority families who do not have access to resources to be able to adequately control and manage their child’s asthma. In collaboration, MDH and MVNA worked together to design and implement a pilot of the Pediatric Asthma Home Visiting Program beginning in August 2018. The pilot consisted of a warm hand-off or referral, within HCMC, referring the pediatric asthma patient to MVNA to continue care services prior to discharge from the hospital. Some of the main outcomes for the warm hand-off pilot program are: (1) Increase knowledge and understanding of asthma diagnosis and recognize that asthma is a chronic disease, (2) increase use of asthma medication and devices – also increase the independence of child to use medication and devices, (3) increase positive attitudes regarding asthma and self-management through Asthma Action Plan (AAP), (4) increase awareness on environmental factors that are asthma triggers, and (5) increase in Public Health Nurse’s (PHN) ability to successfully meet family in their home for asthma home visits. The key learning objectives for the field experience involved exploring and applying methods of working effectively with communities, participating in planning, organizing, and coordinating the components of a program, and applying the theory and skill to practice through work experiences with professional and community colleagues. For the warm hand-off pilot, I conducted an intensive literature review of national studies, cost benefit analyses, and other asthma home visiting programs. I also had data collected on children with asthma within the HCMC database to identify disparities and differences between age, race, sex, and socioeconomic status. I developed the warm hand-off curriculum and aided in the final development of the home visiting program curriculum.

Organization

MVNA is a non-profit organization and the community connections care division for Hennepin Healthcare.⁵ MVNA provides in-home care by working directly in the community through 20+ community-based safety net programs, which span care needs from prenatal and birth, to chronic disease management, to end of life and bereavement.⁵ MVNA focuses on prevention, hospital follow-up, transitional care, supportive services, public health, and finally community health initiatives.⁵ This field experience fit with MVNA’s overall mission by focusing on preventing pediatric asthma exacerbations, working in the communities most affected by poorly controlled asthma, and providing support and education to families in need.

Lessons Learned

MVNA is a small component of Hennepin Healthcare, however, it makes a large impact on the community members and organizations it works with. This field experience strengthened my understanding of how important collaboration on projects from both internal and external partners is when accomplishing a common goal. This experience highlighted the challenges of developing a program from the beginning, while providing me with the tools necessary to conquer these tasks. It became clear that the time dedicated to gathering information and analyzing data to develop the project can take longer than expected. A missed opportunity of coordinating with the Pediatric Care Coordinator occurred when she was on vacation and it was not clear who would contact MVNA when an asthma admission took place. This led to confusion and almost a missed meeting between the MVNA nurse and a family in the hospital. It would have been beneficial to create an action plan to determine who would complete the duties needed to ensure all families in the hospital were able to meet with their MVNA nurse.

Recommendations

There are three top recommendations that surfaced as a result of this project to improve the Pediatric Asthma Home Visiting Program. First, regular meetings with hospital and MVNA staff at the beginning of the program to strategize on the details and methods of the warm hand-off are important. Few meetings took place initially between MVNA and the HCMC staff, which led to more meetings during the pilot to correct issues taking place. Second, regular meetings with MVNA nurses would help in decreasing reported anxiety nurses experienced and ensure they were comfortable during asthma home visits. Moving forward, bi-weekly or monthly meetings to communicate both positive and negative experiences and to continue improving the program is recommended. Lastly, developing a tracking system of the program outcomes, successes, challenges and a cost benefit analysis to monitor the program’s progress towards reaching its intended goals is needed.

Conclusion

MVNA is a key organization making significant health improvements to residents in the Twin Cities area. I am thankful for MVNA and Anna Mueller, my preceptor, for this important project that challenged me to understand public health in a new way. This experience bolstered my passion for public health and helping those in challenged communities. I hope to continue this type of work and creating effective programs for children after graduation.

Resources

1. Sommer, S. J., Queenin, L. M., Nethersole, S., Greenberg, J., Bhaumik, U., Stillman, L., . . . Woods, E. R. (2011). Children’s Hospital Boston Community Asthma Initiative: Partnerships and Outcomes Advance Policy Change. Progress in Community Health Partnerships: Research, Education, and Action,5(3), 327-335. doi:10.1353/cpr.2011.0044
2. Sweet, L. L., Polivka, B. J., Chaudry, R. V., & Bouton, P. (2013). The Impact of an Urban Home-Based Intervention Program on Asthma Outcomes in Children. Public Health Nursing,31(3), 243-252. doi:10.1111/phn.12071
3. United States. Environmental Protection Agency. Office of Air Radiation. (2005). Implementing an Asthma Home Visit Program : 10 Steps to Help Health Plans Get Started.
4. Dong, Z., Nath, A., Guo, J., Bhaumik, U., Chin, M. Y., Dong, S., . . . Adamkiewicz, G. (2018). Evaluation of the Environmental Scoring System in Multiple Child Asthma Intervention Programs in Boston, Massachusetts. American Journal of Public Health,108(1), 103-111. doi:10.2105/ajph.2017.304125
5. (n.d.). Retrieved from https://www.hennepinhealthcare.org/patient-care/mvna/