Fresno tries new approach to combatting asthma (CaliforniaHealthline)

By Alice Daniel, California Healthline Regional Correspondent

FRESNO — Stephani Pineda, a program coordinator for the Central California Asthma Collaborative, has walked through dozens of homes in Fresno County making recommendations to families whose children are at risk of asthma emergencies.

Her mission is to reduce indoor environmental triggers that can cause asthma attacks. Her suggestions range from the simple to the complex, from switching cleaning products to weatherizing a house.

Over the course of a couple of years, she's gotten to know the families well. "You try to build a relationship with the families because it's hard for someone to let you into their home," she said. "The biggest thing for us is they really start to trust us and look forward to our visits. People really do make an effort to make the changes."

It may pay off in more ways than one. The families are part of a unique two-year pilot program in Fresno County called the Asthma Impact Model.

The model focuses on families who are low income. The goal is to see if a social health program can improve care, reduce costly emergency department visits and save money. If the model is successful, it could attract investors to a social impact bond that would allow the program to expand.

The California Endowment funded the project with a $1.1 million grant.

Fresno County's high rates of asthma

Why Fresno County? It has one of highest rates of childhood asthma in the country: one in five children. In fact, asthma is the leading cause of ED visits for kids, and it's the No. 1 health-related reason kids miss school. These numbers put a financial strain on hospitals, schools and Medi-Cal, California's Medicaid program.

Central California Asthma Collaborative and Clinica Sierra Vista, organizations with a history of asthma care and prevention, designed the intervention program.

Coordinators, like Pineda, followed 80 families for one year. They spoke with the parents monthly and made five home visits.

Making a home or an apartment environmentally safe sometimes meant writing letters to the landlord to get mold removed, or get a leak fixed in the bathroom, Pineda said.

And sometimes it was just a matter of taking the time to educate families about medication, like the difference between a rescue inhaler and a long-term inhaler, Pineda said. Some of the kids had been taking the medicine interchangeably. Even if a doctor shows a patient how to use the drugs, it can be so quick that it's hard to understand.

In other cases, Pineda said, parents would worry they were overmedicating their children and only use the inhalers during an asthma emergency, which is actually more harmful.

Children and their parents were taught to recognize asthma triggers, sometimes a hard lesson.

"One of the families had just gotten the cutest little kitten," Pineda said. "The son had been doing really well, and then he started having all these asthma episodes. We found out he was allergic to it."

Kevin Hamilton, deputy chief of programs for Clinica Sierra Vista, said the parents were already making their own efforts; it's just that sometimes they were operating on misinformation. For instance, parents were trying to keep their houses clean and what they thought was environmentally safe, but some were using scented products or strong chemicals that actually exacerbate asthma. Simple suggestions like using green products would often make a huge difference.

Families were also provided with supplies known to improve the household environment like vacuums with HEPA filters and hypoallergenic pillowcases, said Hamilton.

Anecdotal evidence shows huge improvements

Many of the families enrolled in the Asthma Impact Model had previously made visits to an ED several times a year, using it as a source of primary care. "We're now getting families to build a relationship with a primary care physician and to go in for well care visits," Pineda said.

Pineda has seen significant improvements.

"I had one child who always wanted to play soccer when he was little, and he never made it through the whole season. He always ended up in the ED," she said. "Last year, he got to play the whole winter, and also be part of the band."

Hamilton said the program has worked well. "The preliminary results are very good," Hamilton said. "We did see a dramatic improvement in kids' health. School attendance was dramatically improved. Students who were literally failing out of elementary school are now actively participating."

Parents have reported that ED visits fell by about 80 percent, Hamilton said. Asthma-related hospitalizations dropped by approximately 70 percent.

Data may lead to social impact bond

Now it's time to crunch the numbers. With the intervention phase completed, the next phase is an evaluation of Medi-Cal claims data. The Fresno program is the first to use such information to analyze the effect of an in-home asthma intervention program in terms of outcomes and costs.

Connecticut-based Collective Health, which specializes in innovative solutions to health problems, will calculate net savings from the project. The not-for-profit financial intermediary Social Finance will also help determine the feasibility of a social impact bond.

"Once the report happens, the decision is what's next? Does this pencil out?" said Hamilton. "It has huge policy implications."

If the program pans out and banks, individuals and foundations are willing to invest, the program could expand from about 200 children to 3,000. Returns could come from insurers or the state.

The program could "really change the way we look at funding and the expense related to chronic health management, and disease care," Hamilton said.

"I really believe that a fairly small investment on the front end doing work at the person's home in their living room and kitchen is a game changer."

Still, Hamilton said, what really excites him is seeing how the intervention program has positively impacted families.

"The thing that gets to me is hearing these moms tell these stories," Hamilton said. "It just goes to show you, when kids are healthy and in school, good things happen."