Jessica Ramsay, MPH, AE-C Sinai Urban Health Institute

1. Integrating a community-based healthy homes and asthma intervention into a large public housing organization: successes and challenges Jessica Ramsay, MPH, AE-C Sinai Urban Health Institute

2. Outline • Background • Sinai Urban Health Institute • Asthma Epidemiology, Housing and Health • Sinai Asthma Program • Helping Children Breathe and Thrive in Chicago’s Public Housing • Overview • Intervention • Recruitment • Final Outcomes • Lessons Learned and Challenges • What next?

3. Sinai Urban Health Institute • Part of the Sinai Health System – located on Chicago’s urban Westside • Founded in 2000 • Group of epidemiologists, health educators, research assistants, and community health workers • Develops and implements effective approaches that improve the health of urban communities • Main focus is Chicago’s Westside

4. Asthma Epidemiology • Asthma is the most common chronic condition of childhood • Over 10 million children (14.0% of children <18 yrs) in the U.S. have asthma (NHIS 2011) • Rates vary by race/ ethnicity • Puerto Rican 30.0% • Black, non-Hispanic 20.7% • White, non-Hispanic 12.3% • Mexican/ Mexican-American 12.2%

5. Asthma Epidemiology • Inner-city, minority children experience a disproportionate asthma burden • Prevalence approaches 1 in 4 • Sinai’s Community Health Survey • Experience more severe asthma • Mortality and morbidity rates higher in inner-city, minority Chicago communities • More likely to rely primarily on Emergency Department (ED) for asthma care

6. Asthma Epidemiology Public Housing Residents • Public housing residents more likely to be poor and members of racial or ethnic minority, both associated with poor health outcomes (Digenis-Bury, 2008) • Higher rates of asthma documented among federally assisted housing residents (Northridge, 2010) • Public housing is associated with higher levels of environmental triggers that exacerbate asthma (Northridge, 2010)

7. Asthma Control • A person’s home can heavily impact asthma symptoms • Many children and families are in need of individualized education on how best to control asthma • Asthma is a serious lung disease, yet with proper long-term management it can be controlled and children can live normal lives!

8. Four successful previous interventions • Pediatric Asthma Intervention 1 (Michael Reese Health Trust) 2000-2004 • Pediatric Asthma Intervention 2 (IDPH) 2004-2006 • Controlling Pediatric Asthma through Collaboration & Education (IDPH) 2006-2009 • Healthy Home, Healthy Child (CDC) 2008-2011 • Helping Children Breathe and Thrive in Chicago’s Public Housing (HCBT) 2011-2013

9. Helping Children Breathe and Thrive in Chicago Public Housing (HCBT) A Healthy Homes Partnership April 2011– July 2013

10. Overview • SUHI approached the Chicago Housing Authority (CHA) to partner in addressing asthma in public housing on Chicago’s Westside • Funded by the Department of Housing and Urban Development (HUD) • Based on the framework of Sinai’s established CHW home visit asthma program • Translated healthy homes asthma model in six Chicago public housing developments • Utilizes a collaborative approach working with the CHA, building managers, FamilyWorks, and incorporating meaningful participation by the community

11. Hiring and Training CHWs • CHWs are recruited from the CHA properties • No previous asthma knowledge required • Passion for working with community members • 75 hour training conducted by the Sinai Asthma Education Training Institute • Asthma Overview, Home Environmental Assessment, CHW Core Skills, HIPAA and Data collection • Shadowed teaching and role play evaluation • Random shadowing and evaluation throughout intervention

12. Intervention • CHWs are at the heart of the intervention • Provide home-based comprehensive, individualized asthma education • Focusing on medical management (e.g., recognizing and responding to attacks, medication adherence and techniques) • Trigger reduction in the home environment • CHWs link participants with medical and social services

13. Participant Recruitment • Extremely challenging • Partnered with CHA Case Managers • Added four additional CHA sites • Identified a lot of adults with asthma • Children: 1 year intervention with 5- 6 home visits • Adults: 6 month intervention with 3-4 home visits • Eligibility Criteria • Have asthma and live in one of six properties

14. Recruitment Numbers

15. Evaluation • Program evaluation is a significant part of all interventions • Data Collection • Baseline, monthly over the phone, and at home visits • Via self-report • All activities are documented, which allows for robust process and outcome evaluation

16. Program Completion • Adults (6 Month Intervention) • 73 adults enrolled • 81% (n=55) completed intervention • Children (1 Year Intervention) • 85 children enrolled • 71% (n=60) completed intervention • Lost to Study: 24%

17. Demographics * Reporting is different than actual behavior

18. Baseline: Asthma Control Number of participants (n=158)

19. Final Outcomes: Child Asthma Symptoms Children Symptom Frequency in the past 2 weeks at Baseline vs. average during follow-up year (n=59) Days/Nights (max=14) * • * Statistically significant difference (p<0.05) per Wilcoxon signed-rank non-parametric test. A 0.5 point change is also clinically significant

20. Final Outcomes for Children (n=59):Urgent Health Resource Utilization* * Sum Emergency Department (ED) Visits, Hospitalizations, and Urgent Clinic Visits

21. Final Outcomes:Caregiver Quality of Life Pediatric Asthma Caregiver’s Quality of Life (N=42)^ ^This tool is collected once per household * Statistically significant difference (p<0.05) per Wilcoxon signed-rank non-parametric test. A 0.5 point change is also clinically significant

22. Final Outcomes:Asthma Triggers Presence of Home Triggers as Observed During the Home Evaluation Assessment at Baseline and the end of the Intervention for Adult and Child Participants (n=107)

23. Housing Referrals • Collaboration with FamilyWorks, CHA, and property management to develop system of reporting participant housing issues • 30 homes referred with 72 different issues • 86% (62 issues) of housing issues were resolved • Moldy carpeting removed, large cracks and holes filled where rodents and pests were entering, mold from water damage abated, pest control, bed bugs • Results: Participants reported improved asthma symptoms and improved overall quality of life

24. Case Story “I thank you for all of your hard work and the effort you put forth in not only educating us about Asthma and the importance of using safe cleaning products, asthma inhalers and allergy triggers, but improving our overall quality of life at home. It means a lot and I am thankful to have received you as a case manager. I also appreciate that your manner and the way you communicated with us and supported us as a family. Thank you again and sincerest regards,”

25. Lessons Learned & Challenges • Collaboration • Merging two established processes (two cultures) • Finding key players to work with is essential to success • Remaining sensitive to residents individual needs while being sure to follow established CHA protocols • Open and thorough, structured communication from the beginning is key on both ends

26. Lessons Learned & Challenges • CommunityHealth Workers • Quickly and effectively establish relationships of trust with the families that they serve • Support & mentoring of CHWs is vital to success • Effective hiring and training processes are essential • Hire CHWs for skills only they can bring (cultural sensitivity, community connections, etc.). May need support in other areas (e.g., paperwork, managing a case load, computers) 26

27. Lessons Learned & Challenges • Participants • Economic hardship and competing priorities • Multiple caregivers - important to reach all of them • Compliance • Smoking cessation • Medication adherence • Management companies have a process to modifying the home environment 27

28. What next? • Applied for and received additional funding from HUD to work exclusively with adults • Helping Chicago’s Westside Adults Breathe and Thrive, Nov 2013 – Oct 2016 • Continued partnership with CHA • Able to implement established processes with CHA from the previous project with much greater ease 28

29. Teamwork makes the dream work! 29

30. Acknowledgements Chicago Housing Authority Team: Daniel Cassell, Vorricia Harvey, Andy Teitelman, Sinai Team: Kim Artis, Jeanette Avila, Jamie Campbell, Sheena Freeman, Julie Kuhn, Melissa Gutierrez, Rhonda Lay, Helen Margellos-Anast, Pat Perkins, Jessica Ramsay, Gloria Seals, Dennis Vickers, Steve Whitman Funders:Department of Housing and Urban Development – Office of Healthy Homes and Lead Hazard Control Partners: Chicago Housing Authority, Chicago Asthma Consortium, Health & Disability Advocates, Metropolitan Tenants Organization, Sinai Children’s Hospital, & Sinai Community Institute Participants and their families

31. Jessica Ramsay, MPH, AE-C Intervention Director Sinai Urban Health Institute Sinai Health System NR7-142 Chicago, IL 60608 phone: 773-257-2745 fax: 773-257-5347 Jessica.ramsay@sinai.org www.SUHIchicago.org