Clinic-Based vs. Home-Based Support to Improve Care and Outcomes for High Risk Adult Asthmatics

Background: Many Latino and African-American adult asthmatics are at high risk of asthma-related morbidity and mortality and use of urgent care. Factors contributing to their increased risk include low literacy, English proficiency, medication costs, and illness beliefs, among others. Home-based support with community health workers (CHW) successfully addresses many barriers for children, but has not been examined in adults. Practice-based interventions to improve outcomes have shown some promise in adults but generally take piecemeal approaches, focusing on 1 or 2 enhancements like education with less attention to other drivers of outcomes. Optimizing outcomes for adults requires a 3600 approach targeting patients, providers, and systems. Objectives: The primary objective is to compare the relative impacts of home-based and practice-based delivery of chronic asthma self-management support for high risk adult asthmatics on the receipt and use of guideline recommended asthma care and health and quality of life outcomes. Methods: The home- and practice-based models will be adapted for use with high risk adults, pretested, and refined. High risk patients will then be randomized to practice-based intervention (PBI), home-based intervention (HBI), or usual care (UC). For the PBI, an asthma care coach (ACC) will assess inhaler technique, barriers to medication adherence, and appointment keeping and work with patients to optimize self-management. The ACC will follow the patient for 1 year and share data with the patient’s physician. For the HBI, patients will be assigned to a community health worker (CHW) who will provide similar counseling and support services, but in the home. Patients in the UC group will not receive the ACC or CHW driven services. Patients will also be randomized to receive care from physicians exposed to EMR-integrated and guideline-based decision and materials support for inhaled steroid prescribing and asthma action plans. A 3x2 factorial RCT design will be used. Data will be collected through interviews, chart abstractions, and the New York State SPARCS data set to identify hospitalizations and ED visits. Patient Outcomes: Asthma related quality of life, asthma control (measured by FEV1 and self-report), work or school days missed due to asthma, number of ED visits, urgent outpatient visits, and hospitalizations for asthma, and out of pocket spending on asthma-related health care. Partnerships to Facilitate Study: Clinical and academic partners include the Mount Sinai Hospital, the Institute for Family Health, the Jacobi Medical Center, and Northwestern University. Community-based service organizations (CBO) include the Little Sisters of the Assumption of East Harlem, Community Health Works, and Union Settlement. Dissemination partners include the New York State Department of Health and the Greater New York Hospital Association.