Project Name: Healthy Homes Healthy Kids

Project Overview: St. John’s Well Child and Family Center (St. John’s) provides a comprehensive medical home for more than 72,000 patients in South Los Angeles, including approximately 2,500 children with asthma. The burden of asthma and other diseases is exacerbated by social determinants including substandard housing and falls disproportionately on the area’s low-income and minority children. The Healthy Homes Healthy Kids project (HHHK) addressed housing-related asthma triggers by integrating in-home outreach by community health workers and comprehensive case management with team-based primary care. St. John’s partnered with Strategic Actions for a Just Economy (SAJE), a community-based organization focused on tenant rights, healthy housing, and equitable development, to address housing problems and engage with landlords and city agencies in order to improve housing conditions. The project launched at the health center’s Frayser site, which cares for approximately 550 asthmatic children.

The goal of the Healthy Homes Healthy Kids project was to improve health outcomes and advance health equity by intentionally addressing the housing environments that contribute to asthma exacerbations, through direct remediation and housing advocacy.

Key Project objectives were to:

• Enhance comprehensive services for asthma care management to include CHW-delivered in-home education, prevention and case management;
• Identify and ameliorate housing-related asthma hazards such as mold, lead paint chips, dust mites, leaky pipes, rodents, and other asthma triggers from the homes of children with persistent asthma;
• Integrate community health workers (CHW) into the patient care team to help eliminate barriers to asthma self-management;
• Improve asthma control and increase caregiver knowledge to reduce excessive asthma-related emergency room visits and hospitalizations; and
• Promote tenants’ rights and advance improved housing conditions necessary to improve asthma control and sustain health through effective community collaboration.

• • 2017-2018 Project Activities:
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    • Implemented Healthy Homes Healthy Kids model at the flagship Frayser Health Center site;
    • Integrated a community health worker into the patient- and family-centered care team;
    • Implemented baseline, 3-month and 6-month CHW assessments including patient demographics, home environment checklist and asthma control test;
    • Worked closely with providers to ensure appropriate documentation and dissemination of asthma action plans;
    • Worked with MedPOINT Management, Inc. to obtain timely notification of asthma-related hospitalizations and facilitate continuity of care at discharge;
    • Collaborated with SAJE to offer direct services to clients, identify housing quality issues and advocate for housing improvements;
    • Initiated ongoing monthly collaborative meetings with community health workers; and
    • Participated in county-wide Los Angeles Asthma Coalition.
  • 2017-2018 Project Outcomes
    • The Frayser site served 1,526 children with an asthma diagnosis, providing 2,729 asthma care visits;
    • One hundred (100) families were enrolled in the full scope of program services, consisting of in-home asthma education, assessment and remediation of home-based environmental triggers, intensive case management and clinic visits;
    • Seventy-seven (77) families completed a three-month assessment, while 65 families participated in the program for six months;
    • Of those who completed the six month program, there was an average decrease of 60% in ED visits, 75% decrease in hospitalizations, and 95% increase in caregiver knowledge as measured by the Core Caregiver Survey and Home Environment Checklist; and
    • All families were informed of direct services available through SAJE. Approximately 60 engaged with SAJE at some point in the program, and 50 participated in SAJE’s legal clinics and services.
  • 2018-2019 Project Activities
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    • Continued intensive, home-based asthma case management program to complement clinic-based services;
    • Refined and standardized protocols for referral to case management services to focus CHW intervention on the highest-risk/need patients;
    • In partnership with SAJE, continued to provide direct services to families facing harassment from landlords resulting from tenant requests for home repairs or maintenance;
    • Streamlined and improved data collection to capture data complexity, generate structured data for analysis and make information more readily accessible to all members of the care team; and
    • Engaged in advocacy for long-term financial sustainability of services through participation in regional and state-wide coalitions including Regional Asthma Management and Prevention (RAMP), Asthma Coalition of Los Angeles, and the Health Homes Collaborative.
  • 2018-2019 Project Outcomes
    • Enrolled 100 patients in to the Healthy Homes, Healthy Kids (HHHK) program; in-home asthma education, asthma remediation supplies and case management was provided to 100 patients with persistent emergency department (ED) usage;
    • Provided 1,754 asthma care visits to pediatric patients at the health center’s Frayser site;
    • Assisted 28 families in attending SAJE’s mutual legal aid clinic; enrolled 14 families in intensive case management with SAJE to avert/stop landlord evictions in retaliation instead of obtaining necessary repairs needed to address asthma triggers;
    • Created forms in Electronic Health Record (EHR) and used them to collect information gathered by CHW, thereby enhancing communication between medical providers and case managers;
    • Integrated the asthma case management component of HHHK into Health Homes, a program designed to serve eligible Medi-Cal (California’s Medicaid program) beneficiaries with complex medical needs and chronic conditions. Under this program, insurance companies reimburse health centers providing case management services;
    • Over two years, 168 individuals completed the program (32 patients received their six month follow up after the project end date);
    • Of the 168 patients who completed the program by the end of the project period: 100% of participants showed an improvement in asthma symptoms as measured by the Asthma Control Test (ACT) and Core Caregiver Survey; 77% of participants show a reduction in ED usage (the remaining 23% of participants did not increase ED usage); 65% of patients reduced ED usage by 50%, and; 36% of patients have reduced ED usage by 75% or more.

Project Partners: Strategic Actions for a Just Economy, Dignity Health – California Hospital Medical Center, Asthma Coalition for Los Angeles County, Regional Asthma Management and Prevention (RAMP), Californians for Clean Air (CFCA), and Esperanza Community Housing Corporation.

About the Grantee

St. John’s Well Child and Family Center is an independent 501 (c) (3) community health center serving patients of all ages through a network of Federally Qualified Health Centers and school-based clinics that span the breadth of Central and South Los Angeles and Compton. St. John’s seeks to eliminate health disparities and foster well-being by providing and promoting the highest quality of care in South Los Angeles. For more information, visit www.wellchild.org.