Community Health Workers’ Role in Supporting Pediatric Asthma Management: A Review

Abstract

Objective:

Community Health Workers (CHWs) have been effective in improving health outcomes in vulnerable communities by providing health education and management services. We review CHW-led asthma education and management interventions for children and their families. Next, we describe the selection and training of CHWs in pediatric asthma management in the Rhode Island Integrated Response Asthma Care Implementation Program (RI-AIR).

Methods:

We queried the MEDLine, Cochrane, PubMed, and EMBASE databases with keywords (“community health worker”, “asthma”, “health worker”, “lay worker”, “pediatric”, “child”, and “childhood”) from inception until September 2019. Criteria for study inclusion included: published in English, conducted in the United States, approved with an ethics notification, published in peer-reviewed journal, and involved CHWs as the interventionists. The initial search identified 216 manuscripts. Fifteen studies met criteria for inclusion.

Results:

CHWs provide asthma management and education services, including home environmental trigger assessments, strategies to reduce environmental trigger exposure, resource linkage, and community referrals. We describe RI-AIR, and its CHW-led asthma education and management interventions.

Conclusions:

CHWs are effective and vital supports for positive asthma outcomes. More research is needed to guide models of intervention using CHWs, specifically addressing integration in interdisciplinary teams, training, and reimbursement for CHW services.

Implications for Impact Statement:

CHWs are effective in helping children with asthma and their families learn to manage asthma. It is important to develop programs that prepare CHWs to work with other medical professionals and health care models to pay for their services.

Community health workers (CHWs) have been identified as an important resource in enhancing access to health care for chronically underserved communities (American Public Health Association [APHA], 2009). APHA defines a CHW as a frontline health worker who is a member of or closely connected to a community and serves as a liaison between the community, health, and social service systems (2009). CHWs are identified by several titles, including community health advocate, peer leader, lay health educator, outreach worker, peer educator, and patient navigator, among others (Alexander-Scott et al., 2018). CHWs can support individuals by enhancing the linkage with health and social services and ensuring provision of culturally competent services (APHA, 2009; Balcazar et al., 2011; Hohl et al., 2016).

In this manuscript, we provide an overview of the CHW profession and their role in supporting pediatric asthma outcomes. Asthma is the most prevalent pediatric chronic disease (Black & Benson, 2019; Zahran et al., 2016) and its prevalence and severity is influenced by economic and racial disparities as low-income, ethnic minority children are more likely to be diagnosed, utilize the emergency department (ED), and require hospitalization for their asthma (Koinis-Mitchell et al., 2010; Zhang et al., 2017). Greater asthma morbidity is associated with urban areas given poor housing conditions, tobacco smoke, air pollution, and airborne allergens (Kattan et al., 2007). CHW-led interventions can assist in decreasing asthma disparities by 1) enhancing asthma management through improved communication between families, health care providers (HCPs), and school personnel; and 2) supporting improved asthma control through education and trigger mitigation. We review existing literature and describe the CHW role in supporting effective asthma management for children and their families. We then describe an approach for identifying and training CHWs to deliver asthma management education and support to urban, ethnic minority children using the Rhode Island Integrated Response Asthma Care Implementation Program (RI-AIR) as an example. RI-AIR is based on established models that integrate CHW services to enhance health care access and care coordination for children diagnosed with a chronic illness (Martin et al., 2019). We conclude with lessons learned and recommendations for the integration and training of CHWs within pediatric health interventions.

Methods

We reviewed the existing literature to understand the role of CHWs in supporting child asthma health outcomes, focusing on examining their role in: 1) services provided, 2) practice settings, 3) health outcomes, 4) training, and 5) service reimbursement. Provided services included individual and group interventions ranging from asthma education to provider linkage services. Practice settings included HCP offices, in-home services, and community settings.

The following databases were searched: MEDLine, the Cochrane Database, PubMed, and EMBASE. We included studies from inception until September 2019. Key search terms used were “community health worker”, “community health advocate”, “peer leader”, “lay health educator”, “outreach worker”, “peer educator”, “lay worker”, “health worker”, and “patient navigator”, “asthma”, “pediatric,’’ “child”, and “childhood”. Articles were included if the studies were published in English, conducted in the United States, approved with an ethics notification, original research published in peer-reviewed journals, and involved CHWs to deliver asthma education and interventions. The first and second authors reviewed the abstracts and made decisions regarding inclusion and exclusion according to the criteria established above.

Study Selection using Inclusion Criteria

The initial search identified 216 studies (see figure 1, PRISMA diagram). Reviewing the titles and abstracts of these articles indicated that many did not meet inclusion criteria. After review, 15 abstracts met criteria for inclusion, and full text versions were obtained.

Figure 1-.

PRISMA Diagram

Results

CHW Services Provided.

Our literature review indicates that CHWs support pediatric asthma management in a variety of ways (see Table 1). In all reviewed studies, CHWs provided asthma management education, with some demonstrating medication use (Beckham et al, 2004, Breysse et al., 2014, Campbell et al., 2015; Horner et al., 2008; Margellos-Anast et al., 2012). 11 of 15 studies included home environmental trigger assessments, and strategies to reduce exposure to triggers with provision of supplies (Beckham et al., 2004; Breysse et al., 2014; Bryant-Stephens et al., 2009; Campbell et al., 2015, Krieger et al., 2002, Krieger et al., 2009, López et al.,2015; Parker et al., 2008; Primomo et al., 2006; Turcotte et al., 2014; Williams et al., 2006). CHWs supported families’ use of Asthma Action Plans (AAP) by reviewing it with families ( Fisher-Owens, et al., 2011; Fox et al., 2007; Krieger et al., 2002) and obtaining AAPs from the HCP for families (Beckham et al., 2004; Margellos-Anast et al., 2012). CHWs also provided referrals to smoking cessation and housing programs to address environmental triggers (e.g., mold, pest infestation; Fox et al, 2007, López, et al., 2015; Parker et al., 2007). Additionally, CHWs facilitated contact with families, providers, and schools (Fox et al., 2007; Margellos-Anast et al., 2012; Primomo et al.,2006). Service duration ranged from 4 weeks to 14 months.

Table 1.

Selected studies for review.

Author & Location	Age & Eligibility Criteria	CHW Intervention Services Provided & Practice Settings	Asthma-Related Health Outcomes	CHW Training
Beckham S, et al. (2004) Waianae, HI	3–15 years Eligibility criteria: 1. Asthma-related hospitalization 2. And/or ≥1 ED visit in past 45 days n = 48 children	In-office & home education 1. Environment assessment 2. AAP development 3. Medication management 4. Asthma management in-office education Duration: 3 years	Over 1 yr, sum of all participant’s ED visits decreased after intervention (60 to 10). Number of high-utilizers decreased (176 to 16). QoL improved, fewer nighttime & daytime symptoms.	CHWs trained for 11 mo. in anatomy, symptoms & triggers, peak flow meter, inhaler & spacer use, and exercises.
Breysse J, et al. (2014) King County, WA	Families w ≥ 1 children 3–17 years Eligibility criteria: 1. Spoke English, Spanish, or Vietnamese 2. Low income defined by HUD & weatherization programs 3. Not well or poorly controlled asthma n = 102 homes	In-home Education and Environmental Intervention 1. Environment assessment 2. Bedding covers, vacuum, cleaning kit, peak flow meter, inhaler, spacer, & medication box 3. Written material on asthma trigger reduction Duration: 4 sessions over 1 yr, follow-up assessment 1 yr after	Study group percentage with poorly controlled asthma decreased more than comparison group (100% to 28.8% vs 100% to 51.6%, p = .04). Study group caregiver QoL improvements exceeded comparison by 0.7 units (p = .002). Decrease in study group’s triggers (p = .089).	Not mentioned.
Bryant-Stephens T, et al. (2009) Philadelphia, PA	2–16 years Eligibility Criteria: 1. MD-diagnosed asthma 2. Taking controller medication 3. ≥1 inpatient visit or 2 ED visits within past yr n = 264 children	In-home Education and Environmental Intervention 1. Asthma education 2. Environment assessment 3. Mattress/pillow covers, roach bait, mice traps, cleaning kit, window shades, tiles, & storage bins Duration: 3 yrs. Active phase = 5 visits, biweekly follow ups for 24 weeks; Inactive phase =1 visit/mo. for 6 mo.	Yearly ED visits decreased by 30%, inpatient visits decreased by 53% (p < .001). Reductions in pests, presence of carpet in bedrooms, and dust. Nighttime wheezing reduced after intervention (p < .001).	Didactic training on asthma, trigger removal methods, asthma device usage, medications. Buddy-method and mock scenarios used until competency was proven. Study design and data collection taught.
Campbell J.D, et al. (2015) Seattle, WA	3–17 years Eligibility Criteria: 1. Not well or very poorly controlled asthma 2. Enrolled in 1 of 2 Medicaid plans 3. Caretaker spoke English or Spanish n = 373 children	In-home Education and Environmental Intervention 1. Education, support, & service coordination via home visits, phone, e-mail 2. Vacuum, cleaning supplies, roach bait, bedding covers 3. Device usage coaching Duration: 4 visits in 1 yr	Intervention group: improvement in symptom-free days (2.10 days more over 2 weeks; p < .001) & caretaker QoL (1.31 events fewer over 12 mo.; p = .001).	This was a streamlined version of the RCT done by Krieger J, et al. See CHW training under that study for more information.
Fisher-Owens S.A, et al. (2011) San Francisco, CA	0–21 years Eligibility Criteria: 1. Patients seen for visits at pediatric asthma clinic 2. Had not received home visits n = 364 children	Telephone Case Management 1. Asthma education 2. AAP Review 3. Environmental control education 4. 2 week telephone follow-up with new AAP, education, & pharmacy issues assistance Duration: Clinic visit with 2-week telephone follow-up	CHWs addressed all knowledge deficits of medications & emergency response. 83.2% of patients reached by phone. Latino patients more likely unable to be contacted (p < .001). Phone follow-up seems effective to contact low-income, minority patients.	Not mentioned.
Fox P, et al. (2007) CA	5–18 years Eligibility Criteria: 1. Moderate/severe persistent or poorly controlled 2. ≥1 clinic visits in past yr 3. Community clinic patient n = 965 children	In-office education 1. CHW provided links between providers, home situation, school, and community 2. Introduction of AAPs 3. Provider and staff training Family & patient education Duration: 4 years	Over past 6 mo.: improvements in severity, symptoms, AAP review, & health utilization, fewer acute visits & school absences. Increased reports of good quality of care & confidence in self-management. p < .0001 for all comparisons.	Conducted outreach & trained to provide referrals. They were a part of each clinic’s Continuous Quality Improvement (CQI) team.
Horner S.D, et al. (2008)	Grades 2–5 Eligibility criteria: 1. MD-diagnosed 2. Symptoms in past 12 mo. 3. No co-morbidity 4. Spoke English or Spanish 5. Attending rural school n = 183 children	In-school Education 1. Education during school lunch breaks 2. Skills practice with placebo MDI and peak flow meters Duration: 16 sequential 15-min. sessions over 12 weeks	Treatment group increased asthma knowledge scores by 10% vs. control group increase of 5% (p = .03). Small increases in scoring for self-management, self-efficacy, and metered dose inhaler technique.	Not involved in data collection. 16 hrs training from PI with feedback session. Member of the research team observed sessions to assess CHWs.
Krieger J.K, et al. (2002) Seattle, WA	4–12 years Eligibility Criteria: 1. MD-diagnosed persistent asthma 2. Income < 200% federal poverty threshold or enrolled in Medicaid 3. Caregiver proficient in English, Spanish, or Vietnamese 4. Child spent 50% of nights in house n = 274 children	In-home Education and Environmental Intervention High-intensity group: 1. Environment assessment 2. AAP review 3. Bed covers & vacuums 4. Social support & advocacy Duration: Initial visit + 6 follow-ups over 12 mo. Low-intensity group: 1. Environment assessment 2. AAP review 3. Limited education 4. Bed covers Duration: Initial + exit 1 yr later	Reduced asthma symptom days and urgent health services use over past 6 mo. Improved caregiver quality-of-life score. Improvement was greater with a higher-intensity intervention.	40-hr training program and 10–20 hrs of continuing education per yr. Met PI every 2 weeks, steering committee every 2–3 mo. to review protocols. 6 hrs of training in cultural competency. Were full-time, salaried, & involved in program design / evaluation.
Krieger J.K, et al. (2009) Seattle, WA	3–13 years Eligibility Criteria: 1. MD-diagnosed or poorly controlled 2. Income < 200% federal poverty threshold or Medicaid enrolled 3. Spoke English, Spanish, or Vietnamese n = 309 children	In-home Education and Environmental Intervention 1. Environment assessment 2. Follow-ups: progress assessment, education, social support 3. Bed covers, vacuum, doormat, cleaning kit, & medication boxes Duration: 1 intake & 4–5 follow-ups over 1 yr	Both groups (same as above) = increase in caretaker QoL & symptom-free days, decrease in usage of urgent health services in past 3 mo. Nurse + CHW group only = QoL improved by 0.22 points (p= .049), symptom-free days increased by 0.94 per 2 wks (p = .046).	Same as above.
López R, et al. (2015) New York City, NY	17 years or younger Eligibility Criteria: 1. Residence in East Harlem public housing 2. Severe/persistent asthma 3. Environmental hazards documented by a CHW n = 60 children	In-home Education & Environmental Intervention 1. Individualized education & trigger remediation plan 2. Housing authority referrals 3. Equipment loans (vacuum, air cleaners, bed covers, cleaning supplies, food storage) Duration: Baseline and 2 follow ups at 6 and 12 mo.	Over 2 weeks, decreased nighttime awakening, use of medication, and asthma-related yearly ED visits (all p < .001). Decreased environmental hazards (p < .05). Caregivers reported decreased symptoms, improved housing conditions, and CHW appreciation.	Briefly mentions the CHWs are trained in environmental health.
Margellos-Anast H, et al. (2012) Chicago, IL	2–16 years Eligibility Criteria: 1. African-American 2. Severe, poorly controlled asthma n = 50 children	In-home Education 1. Individualized education 2. Medication usage education 3. Establishment of relationship with PCP 4. AAP obtainment Duration: 3–4 visits over 6 mo.	Symptom frequency reduced by 35% (p < .05) & urgent health utilization by 75% (p < .0001) over past 6 mo. Improved parent QoL score (5.2 vs 6.5, p < .05), knowledge, & management. Decreased trigger exposure.	No prior asthma experience needed. 5-day training. Continuous education with intervention coordinator & pediatric pulmonologist.
Parker E.A, et al. (2008) Detroit, MI	7–11 years Eligibility Criteria: 1. Attended 1 of 44 elementary schools 2. Persistent asthma 3. Spoke English or Spanish n = 298 households	In-home Education & Environmental Intervention 1. 1st visit: asthma information & environment assessment 2. 2nd visit: house action plan 3. 3rd-9th visits: education, exterminator referral, vacuum, mattress/pillow covers, & cleaning supplies. Duration: 9 visits over 1 year	Increased FEV1 (p = .03) & peak flow (p = .02); reduced symptom frequency, ED visits over 3 & 12 mo., & inadequate controller use. Reduced study group parents’ depressive symptoms vs increase in control (p = .0218). Increased trigger reduction behavior.	CHWs trained for 4 weeks (ongoing for the remainder of the year) in providing referrals, strategizing behavior change, and applying pest management.
Primomo J, et al. (2006) Tacoma-Pierce County, WA	0–18 years Eligibility criteria: 1. Families with ≥1 child who received CHW services for asthma 2. Spoke English 3. Had a telephone n = 60 households	In-home Education and Environmental Intervention 1. Education & environmental assessment 2. Email/phone follow-up 3. Mattress/pillow covers, doormats, spacers, & peak flow meters 4. Letters sent to provider with recommendations Duration: 2–26 weeks	Higher caregiver QoL (p < .001). 93% had AAPs compared to 31% at baseline (p < .001). Reduced yearly hospitalizations (30.9 to 18%, p = .01). All families made changes to minimize triggers. Caregivers reported high CHW satisfaction.	CHWs were trained in home visits, home environmental assessments, and providing asthma education.
Turcotte D.A, et al. (2014) Lowell, MA	Younger than 15 years Eligibility criteria: 1. MD-diagnosed 2. Resided majority of nights in household 3. Spoke English, Spanish, or Khmer n = 170 children	In-home Education and Environmental Intervention 1. 1–2 hr environmental walkthrough 2. Pest remediation, cleaning services, education, & structural interventions Duration: 4–9 visits in 1 yr. Assessments at 6 and 12 mo.	Statistically significant health improvement from baseline to follow-up. Drop from 85 to 59% of children using quick relief medication (p < .001). Reduced health care utilization from 8 to 4 visits over past 4 weeks.	Not mentioned.
Williams S.G, et al. (2006) Atlanta, GA	5–12 years Eligibility criteria: 1. ED visit 2. Spoke English n = 161 children	In-home and in-clinic Education and Environmental Education 1. Asthma management info. verbally & via brochures 2. Dust mite covers, professional house cleaning, & cockroach gels Duration: Home & clinic visits & phone follow ups every 4 mo. over 14 mo.	Stable dust mite levels in intervention group vs 163% increase in delayed intervention (p < .05). Severity scores unchanged. Intervention group FSSs improved 25% compared to delayed intervention (p < .01). No significant difference in medication use & yearly ED visits.	CHWs trained for environmental assessments, interviewing, & laboratory samples. They were the primary case managers interacting with children & families.

Note: AAP = Asthma Action Plan, CHW = Community Health Workers, CI = Confidence Interval, ED = Emergency Department, FEV1 = Forced Expiratory Volume, FSS = Median Functional Severity Score, HUD = Housing and Urban Development, hr/s = hour/s MD = Medical Doctor, MDI = metered dose inhaler, min. = minute/s, mo. = month/s, PI = Principal Investigator, QoL = quality of life, yr/s = year/s

CHW Practice Settings.

Most interventions described (n=12) involved both in-home and office-based settings. Three included only one setting: telephone case-management (Fisher-Owens et al., 2011), school-based (Horner et al., 2008) or office only (Fox et al., 2007).

Health Outcomes.

Results indicated improved asthma health outcomes for participants who received CHW services. Most studies compared asthma outcomes pre- and post-intervention. Targeted health outcomes ranged from asthma-related functioning, such as asthma control, to healthcare use (ED visits). One study compared the addition of weatherization to an existing CHW home visit education program (Breysse et al., 2014), while another compared a high-intensity CHW education intervention to a low-intensity one (Krieger et al., 2002). Findings indicated CHWs support improved asthma control (Breysse et al., 2014), increased symptom free days (Beckham et al, 2014; Campbell et al., 2015; Fox et al., 2007; Krieger et al., 2002; Krieger et al., 2009), decreased nighttime symptoms (Beckham et al, 2014; Bryant-Stephens et al., 2009; López et al., 2015) and ED visits (Beckham et al., 2004; Bryant-Stephens et al., 2009; López et al., 2015). Results also included improved caregiver quality of life (Beckham et al, 2014; Breysse et al., 2014; Campbell et al., 2015; Krieger et al., 2002), asthma knowledge (Fisher-Owens et al., 2011, Horner et al., 2008) and asthma management self-efficacy (Horner et al., 2008). While 11 interventions included trigger assessment and remediation, only four indicated outcomes related to trigger exposure (Breysse et al., 2014; Bryant-Stephens et al., 2009; López et al., 2015; Williams et al., 2009). Table 1 includes further details.

CHW Training.

Information about CHW training was not consistently presented in the reviewed studies. Three manuscripts did not include any information (Breysse et al, 2014; Fisher-Owens et al., 2011; Turcotte et al, 2014). When reported, training given to CHWs ranged in duration, format, and topics. Topics included anatomy and physiology of asthma, asthma symptoms and triggers, severity classifications, asthma medications, peak flow meter, inhaler and spacer use/care, and relaxation and strengthening exercises (Beckham et al., 2004). CHW training also included cultural competence focused on effective communication with diverse Clients (Campbell et al., 2015; Krieger et al., 2002, and 2009), environmental trigger exposure assessment (Parker et al.,2008; Primomo et al., 2006), and research procedures (Bryant-Stephens et al., 2009). For two interventions, training included ongoing supervision with a pediatric pulmonologist and asthma-related continuing education (Krieger et al., 2002; Margellos-Anast et al., 2012).

Service Reimbursement.

Only four studies included information regarding cost of intervention and potential return on investment (ROI). These studies reported a reduction in health care costs or ROI for those who benefited from CHW services in comparison to those who did not (Beckham et al., 2004; Campbell et al., 2015; Margellos-Anast et al., 2012; Turcotte et al., 2014). Beckham and colleagues (2004) reported an average decrease per capita from $785 to $181 in asthma-related health care visits during the intervention period. Another study reported an estimated overall cost savings of about $71,162 over a year (Turcotte et al., 2014).

Summary of Results.

Consistent with chronic disease literature, CHWs play an important role in supporting positive asthma outcomes. CHWs serve in a variety of roles that are consistent with the APHA (2009) definition. Services provided included health education, environmental assessments, case management, and enhancing communication between children, caregivers, and HCPs. However, limited information is available about CHW selection criteria and the content, length and quality of training provided to CHWs. Additionally, very few studies included information regarding costs and the ROI associated with CHW-led interventions.

An Exemplar: The Rhode Island Asthma Integrated Response Program (RI-AIR)

The National Heart Lung and Blood Institute (NHLBI) funded four Asthma Care Implementation Programs (ACIP) that aim to provide comprehensive care for children at high risk of poor asthma outcomes (NHLBI, 2016). RI-AIR, one of the funded ACIPs, includes: 1) identification of children (ages 2–12) at risk for morbidity from multiple referral sources into one secure technological platform, and 2) referral to programs based on asthma control screening using an evidence-based algorithm (NHLBI, 2007). Drawing on the CHW literature, one of the primary components of the RI-AIR model is enhanced communication between family, HCP, and school nurse teacher (SNT) which is facilitated by the CHW team (APHA, 2009; Martin et al., 2019). Additional RI-AIR components derived from the literature are CHW care coordination and CHW-led assessment and remediation of asthma triggers in the home (Martin et al., 2019). Given limited information regarding training, we focus on CHW selection, ongoing professional development, and interdisciplinary team and research integration (Hohl et al., 2016; Martin et al., 2019). The local hospital’s Institutional Review Board approved RI-AIR.

CHW Services.

Two evidence-based programs are implemented through RI-AIR (see Figure 2): the Home Asthma Response Program (HARP) and Controlling Asthma in Schools Effectively (CASE). CHWs work in both programs and maintain a caseload of HARP and CASE participants. For both, the CHWs’ main role is to support families to obtain an updated AAP from the HCP. In HARP, CHWs actively provide asthma trigger remediation support while in CASE, they enhance connections with schools by making AAPs accessible to the school nurse.

Figure 2:

RI-AIR participant intervention and research diagram

HARP is a home-visit program that includes guidelines-based asthma management education. It involves three home visits with a CHW providing case coordination and support. In the first visit, the certified asthma educator (herein referred to as educator) is responsible for providing asthma education and discusses self-management strategies using a structured protocol and low-literacy flipbook (in English or Spanish). Next, the CHW and educator administer a “walk-through” to identify asthma triggers in the home. Finally, the CHW and educator work together with the caregiver to develop goals to enhance to enhance the child’s asthma management and control. The CHW is responsible for referrals and providing advocacy to address asthma management barriers (e.g. landlord/housing or social issues). The second visit, conducted by two CHWs, to deliver supplies (e.g. HEPA vacuum, pest gels, mattress covers), usage instructions, and goal follow-up. At the third visit, two CHWs complete a final environmental walk-through, address any concerns, and review the AAP.

CASE is a multi-level school-based program led by an educator that includes 1) child asthma education in a group setting during school, 2) afterschool caregiver education, 3) school staff training on asthma education and management, and 4) school environmental assessment. The child/caregiver educational program, open to parents of young children, uses a guidelines-based approach (NHLBI, 2007). The CHW also reviews updated AAPs with caregivers.

CHWs also conduct eligibility screening and ensure CASE and HARP participants receive a current AAP from their health care provider. Once an AAP is available, the CHW reviews it with the caregiver and uploads it to a statewide child healthcare database, which allows providers and school nurses to easily access it. CHWs participate in recruitment and outreach events in schools, local health centers and other community events.

CHW Practice Settings.

The HARP intervention is home-based while CASE is school-based. Additionally, CHWs have ongoing phone contact with families and providers to facilitate AAP completion and support families’ communication with providers (healthcare and school).

Health Outcomes.

The primary health outcome addressed in RI-AIR is asthma control, an important clinical target (NHLBI, 2007) for children with asthma. As seen in the review, CHW-led education and trigger remediation interventions support improved asthma control (Breysse et al., 2014). A secondary outcome is AAP accessibility to school nurses, a critical component of the RI-AIR CHW role. Given this is an ongoing trial, outcome data are not yet available.

CHW Training.

CHWs were recruited from Greater Providence and were either bilingual Latino (English/Spanish) or African American. The job posting was disseminated through the hospital’s website, local CHW list-serves, and presentations to CHW training program staff. Most applicants did not have prior experience with asthma. CHWs were selected based on health education, community work experience, and interpersonal skills.

CHWs participated in our intensive orientation program. Training included a 40-hour training addressing the core competencies for CHWs, and foundations of motivational interviewing. RI-AIR CHWs participated in home environment assessment trainings through the National Center for Healthy Housing. This included a three-hour online Healthy Homes overview training followed by a three-day home environmental assessment training. A mock home environmental assessment and asthma-specific environmental trigger exposure training were included. CHWs participated in the standard hospital on-boarding training and complete the Collaborative Institutional Training Initiative research training certification. Additional training included home visiting safety, and child abuse and neglect reporting. In the event of a health or mental health emergency, CHWs are trained to follow up with the clinical supervisor to identify appropriate resources for the caregiver and child.

As part of the training process, CHWs accompany our current staff to observe program implementation directly. The CHW training plan involves observing experienced staff completing the home visits and other aspects of the interventions. Training includes the use of a standardized manual and a fidelity checklist to assess the extent to which interventions are delivered in a consistent manner. CHWs are expected to gradually begin to administer portions of the intervention until they reach mastery and independence. Typically, CHWs complete three observations, co-lead three interventions, and finally lead an intervention on their own. The clinical supervisor observes the CHWs in training, provides feedback, and with the CHW determines when the individual is ready to independently lead the interventions.

The RI-AIR clinical supervision approach involves weekly meetings with educators and CHWs to review case progress (e.g. obtaining/reviewing AAP). At these meetings concerns related to the children and families served, and additional trainings are addressed. A PhD-level clinical supervisor provides supervision and oversees training activities. The clinical supervisor periodically observes sessions to provide ongoing support and supervision. CHWs are encouraged to participate in professional development initiatives. CHWs may join the local CHW association’s mailing list. Individuals attend trainings relevant to their role and/or unique interests. Monthly individual supervision meetings allow for mentorship and support regarding individual professional goals (e.g., CHW certification).

CHWs are integral to the research conducted. They participate in weekly meetings with research staff and provide feedback regarding research implementation. CHWs meet monthly with the principal investigators to discuss topics relevant to intervention and research procedures. Additionally, the CHWs complete a monthly anonymous feedback survey that is shared with project leadership. This feedback is part of a larger process evaluation component of RI-AIR and is then used to make changes to the implementation plan, and program procedures.

Service Reimbursement.

RI-AIR is a research funded-initiative. HARP was included in a state-funded economic analysis used to advocate for service reimbursement. Our team is currently piloting a similar model funded by a Medicaid managed-care organization.

Recommendations and Lessons Learned: the CHW in Pediatric Asthma Care

The literature shows that CHW-led interventions improve asthma outcomes for children. Our review and experience indicate that CHWs’ integration within interdisciplinary teams, their continued professional development, and CHW service reimbursement models are issues that need further consideration. Below, we outline lessons learned and recommendations.

CHW Services.

Our review of the literature highlights the importance of CHWs in supporting improved asthma outcomes for children. Next steps in research include identifying specific aspects of CHW-led interventions (health education, case management) most effective in improving health outcomes. For example, while many of the interventions reviewed included trigger assessment and remediation, it is unclear if improvements were achieved as these results were not included. Additionally, while linkage and care coordination are significant services provided by CHWs, there are challenges in quantifying these services and assessing their impact on asthma outcomes. For RI-AIR, tracking the number of AAPs uploaded to the statewide child healthcare database is a concrete tool to assess the success of the CHW coordination services.

CHW Practice Setting.

CHWs are in a unique role where they can reach children and their families in a variety of settings. The reviewed studies made use of this strength and highlight the effectiveness of flexibility in service delivery locations. Challenges include CHW integration within these settings, including medical offices, schools, and other locations. The studies indicate a need for procedures that foster collaboration and communication between interdisciplinary team members. Consistent with the literature and RI-AIR, CHW participation in regular supervisory and interdisciplinary meetings helps to identify and address CHW concerns, enhance intervention protocols and procedures, and ultimately improve quality of care. Additionally, these efforts contribute to CHWs feeling valued and integral to the team, which contributes to the program’s success. Furthermore, concerns about safety and emergency procedures require additional training and ongoing supervision. Future interventions need to clearly articulate the role of CHWs and educate HCPs, and families about the CHWs scope of practice. Developing and disseminating successful models of CHW integration in different settings is vital to integrated health care models. For RI-AIR, creating procedures for successful CHW integration has been an iterative process, requiring ongoing evaluation and adjustments.

CHW Training and Supervision.

Nationwide competence criteria are vital to ensure a quality CHW workforce. Ongoing professional development opportunities and communicating CHWs’ value and skills are crucial to interdisciplinary team success. CHWs’ participation in local CHW organizations is essential for their professional status. To support effective CHW workforce development, clear and detailed descriptions of training models are needed. Similarly, further research is required to identify essential training aspects and those that can be discarded. The RI-AIR supervision and training model provides a template for future programs.

Service Reimbursement.

There is limited research addressing CHW service payment models. Currently, some states have laws authorizing Medicaid reimbursement (CDC, 2017, Rosenthal et al., 2010) for services, but developing accountable care organizations or capitated systems may better sustain CHWs within a multidisciplinary team model. Payment models must allow flexibility in service location (e.g. home, community). Implementation research outlining effective models is needed to improve CHW integration in healthcare and community settings. Legislation at the state and national level is required to support CHW service reimbursement.

In summary, CHWs enhance health care access and health outcomes for children and families. However, a fine-grained understanding of the aspects of CHW-led interventions that enhance health outcomes is necessary. Further work is needed to establish consistent guidelines for CHWs’ professional role and training. Future research focused on developing and testing models for CHW service reimbursement will ensure the sustainability of the workforce and of CHW-led health interventions.