Expanding Home Visiting to Other At-Risk
Populations:
Asian Americans and Other Populations Not Well
Connected to the Medical Home
• Johnna S. Murphy, MPH, Boston Medical Center
• Eugene Barros, BA, Boston Public Health Commission
• Sherry Dong, MPA, Tufts Medical Center
National Healthy Homes Conference
Nashville, TN
May 28th, 2014
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1. Engage & leverage culturally specific
neighborhood and community partnerships
2. Train inspectors
3. Early Warning System (to assist tenants in
maintaining their housing)
4. Healthy Homes for Children with asthma in
high risk populations (education & interventions)
5. Landlord Engagement and legal advocacy
2
• How can asthma home visiting
programs (delivered by a Community
Health Worker) reach underserved
populations?
• How do we engage families who are
hard to reach, such as those not
connected to a medical home or
those who are linguistically isolated?
• How do we retain these families
within a program?
3
Evaluate two models of recruitment for an asthma
CHW home visiting program:
• Tufts Medical Center (Tufts MC) targeted Chinese
through Tufts MC
• BPHC targeted families who might not have a
medical home by recruiting through housing support
programs
Funded by HUD and EPA: Primary Grantee=Boston
Public Health Commission, with support from Boston
Medical Center and Tufts MC
4
What is a CHW?
American Public Health Association:
Is a trusted member of, or
deeply understands, the
community served
Is a liaison between health and
social services and the
community

A CHW builds individual and
community capacity through:
Outreach
Community education
Informal counseling
Social support
Advocacy

BPHC CHW Nathalie Bazil
demonstrates proper use of
spacer in Boston home
5
CHWs and Asthma Home Visits
• CHWs deliver asthma and medication
education in the home
• CHWs offer advice and tools for
reducing asthma triggers
• CHWs provide referrals and advocacy
• Studies support effectiveness of multicomponent home visit interventions in
improving asthma outcomes and
reducing urgent care use.
6
• CHW asthma home visiting programs
have historically been successful in
Boston
• Evidence supports strong clinic
integration and communication
between families, CHWs, and
providers
• Challenges include recruiting and
retaining hard to reach families
• Those not connected to a clinic or
medical home
• Those linguistically or culturally
isolated from providers
7
• BPHC utilized trusted community and housing partners
and integrating referral into existing systems:
• Breathe Easy at Home-a web based system that
allows health care professionals to directly refer to
inspectional services
• Metropolitan Boston Housing Partnership-a city
wide Section 8 administrator that reaches thousands
of low income tenants each year
• These programs referred families to BPHC for a BPHC
CHW delivered home visiting intervention
8
• Asian immigrants tend to
underutilize health care services
• often lack the information
necessary to practice preventive
health maintenance.
• cultural differences and linguistic
barriers, financial concerns, such
as lack of health insurance.
• > 50% of Boston Chinatown
residents are non- or limitedEnglish proficient
9
• part of The Asthma Prevention and Management
Initiative launched by Tufts MC and the Floating Hospital
for Children
• aims to improve the outcomes of children with asthma and
decrease utilization of acute care services for asthma-related
problems.
• Families were recruited through Tufts MC pediatric clinics
(strong ties to the medical home)
• CHW and program manager was from the community and
understood culture and local resources
• CHW fluent in Cantonese, Mandarin, and English
• But what about families not connected to a medical home?10
CHWs conducted surveys and environmental
assessments:
• environmental triggers (measured by dust, mold,
pests, pets, smoking, and chemical use)
•Asthma Control Test
-health care utilization
-quick-relief and controller use
-symptom days
•Perceived Stress Scale
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Both Tufts MC and BPHC CHWs provided
the same intervention:
• 3 protocol defined home visit interventions
and 1 follow up phone call
• support and education on home
maintenance (including house cleaning)
• pest control education and IPM services
• environmental tobacco smoke education
• Supplies (HEPA vacuum, cleaning kit,
traps, allergen blocking mattress covers)
• connected children and families to needed
medical treatment and case management
12
60
50
50
40
40
30
Total Enrolled
34
26
26
29
20
Completed 3 visits
Completed 6
month Follow Up
10
0
BPHC
Tufts MC
Number of families enrolled, completed intervention, and
completed follow up by site
13
BPHC %
(n=50)
Tufts MC % Combined %
(n=32)
(n=82)
Black
70
13
48
Asian
2
81
33
White
18
3
12
NH/PI
0
3
1
Other
10
0
6
Race
14
English
Haitian Creole
Spanish
Portuguese
Cantonese
Toisanese
Mandarin
Vietnamese
BPHC%
(n=50)
90
4
4
2
0
0
0
0
Tufts MC%
(n=32)
23
0
0
0
59
3
13
3
Combined %
(82)
63
2
2
1
23
1
5
1
15
BPHC %
(n=30)
2
Tufts MC% Combined %
(n=32)
(n=62)
13
6
12
22
16
14
34
22
40
13
29
College, Grad or 12
Post Grad
13
12
Less than 8th
grade
Some High
School
High School or
GED
Some College
16
A score of 19 or less indicates not well controlled asthma
25
20
15
BPHC
Tufts MC
10
Combined
5
0
Visit 1
Visit 2
Visit 3
6 month
Follow up
17
100
80
60
BPHC
Tufts MC
40
Combined
20
0
Visit 1
Visit 2
Visit 3
Percentage of Families with Asthma Action Plan by visit
18
100
80
60
40
BPHC
20
Tufts MC
Combined
0
19
100
80
60
BPHC
40
Tufts MC
Combined
20
0
Visit 1
Visit 2
Visit 3
Percentage of families with pests by visit
20
100
80
60
BPHC
40
Tufts MC
Combined
20
0
Visit 1
Visit 2
Visit 3
Percentage of families with pets by visit
21
100
80
60
BPHC
40
Tufts MC
Combined
20
0
Visit 1
Visit 2
Visit 3
Percentage of families with smoking allowed in home by visit
22
Percentage of families with mold by visit
23
Percentage of families with dust by visit
24
100
80
60
BPHC
40
Tufts MC
Combined
20
0
Visit 1
Visit 2
Visit 3
Percentage of families who use abundant chemicals by visit
25
6
5
4
BPHC
3
Tufts MC
Combined
2
1
0
Visit 1
Visit 2
Visit 3
A sum of total triggers was calculated (pests, pets, smoking,
mold, dust, and chemicals).
Average Trigger Scores by Visit
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• BPHC was successful in recruitment
• Fewer follow-up visits but 80%
completed six month follow-up.
• Many BPHC participants self-referred
• High levels of ED and hospitalization at
baseline
• Recruitment through housing and public
health should be considered.
27
• Tufts MC was successful in retaining families,
with 76% completing intervention, as opposed
to 52% of BPHC
•Cultural and linguistic competence
•Families seeing value in the APMI program
•Interdisciplinary APMI team
•Tufts MC clinic base of operations for
CHWs/APMI staff
28
• Both groups saw positive results
• Very different at baseline
• Reduced urgent care utilization, improved ACT scores,
and lower environmental triggers
• Strong cultural understanding, ability to act as health
care bridge
• Both needs targeted programs
29
• Despite universal health care in Massachusetts,
many of the BPHC subjects had very poor
asthma control but no access to medical home.
• Willing to self identify
• How do we continue to reach these families for
home visiting and connect them to clinical care?
• BPHC families possibly were more stressed, had
worse health outcomes, etc. making keeping
appointments more difficult?
• How do we ensure successful completion of
program, once recruited?
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HUD Demonstration Grant MALHH-0207-09
Environmental Protection Agency
Megan Sandel, MD, MPH at Boston Medical
Center
Margaret Reid, RN and Nathalie Bazil at
Boston Public Health Commission
May Chin, RN and Brenda Situ at Tufts Medical
Center
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