Developing Core Components of the Program

Health plans and health organizations can support the expansion of asthma home visiting services in their communities in multiple ways such as: building on an existing asthma management program to include home visits, developing a new program within the health plan or health care organization, or contracting with an organization that can provide the services to health plan members or patients.

The first step is to organize a team that can determine the best path forward. If a health plan or health care organization has an existing asthma management program but does not yet include home visits, they may already have a team in place that could implement a home visiting program. If they must form a new team, it could include a medical director, director of quality, asthma or other chronic disease case manager, physicians, nurse practitioners, nurses, respiratory therapists, health educators, and community health workers. The implementation team will need to determine the program’s goals, components, and implementation plan.

Here are some of the key questions for the team to discuss.

Who will provide asthma education?

The Association of Asthma Educators defines an asthma educator as “an expert in teaching, educating, and counseling individuals with asthma and their families in the knowledge and skills necessary to minimize the impact of asthma on their quality of life. The educator possesses comprehensive, current knowledge of asthma pathophysiology and management including developmental theories, cultural dimensions, the impact of chronic illness, and principles of teaching-learning.”

Licensed and non-licensed professionals with appropriate training (see 'Implementing the program' for more information) can provide in-home asthma education. A variety of professionals can be trained as asthma educators including respiratory therapists, nurses, health educators, and community health workers (CHWs). Organizations may choose to employ asthma education staff directly (train existing staff or hire new staff) or contract with a local organization that already employs asthma educators. In addition to training in asthma self-management education, it is important that asthma educators have competencies around cultural and linguistic needs of the communities they serve to build the trust and rapport needed to provide home visiting services.

How will the program be funded?

Sustainable financing for asthma home visiting may come from multiple sources, both short-term (such as grants) and long-term (such as health services reimbursement) funding streams. Health plans and health care organizations may have the ability to hire or contract with asthma educators to provide asthma home visiting using their administrative budgets. See 'Resources' for resources around funding options and 'Appendix' for a health system model for asthma self-management education implementation.

Who will be eligible for the program?

Organizations need to determine eligiblity criteria based on their priorities and capacity. Research studies suggest that comprehensive asthma home visiting services are most effective for people with poorly controlled asthma. Health plans or health care organizations may choose to limit eligiblity to those with poorly controlled asthma to most effectively direct limited resources and optimize the return on investment.

Potential criteria that could be used to identify patients with poorly controlled asthma include:

• Asthma Control Test (ACT) score of 19 or less.
• One or more asthma-related ED visit and/or hospitalization for asthma in last 12 months.
• Asthma medication ratio (AMR) of <0.5.
• Use of oral corticosteroids in last 12 months.
• Provider referral for incorrect medication use or frequent office or urgent care visits.

Eligible patients can be identified through review of electronic medical records or claims data if available and/or referred from within or outside of the organization by health care providers such as primary care providers and asthma and allergy specialists, case managers, or school nurses.

What components will be provided?

There are several components of typical asthma home visiting programs, including Wisconsin’s Asthma-Safe Homes Program. Organizations can decide to what extent the following components will be provided to clients participating in the program.

• Asthma self-management education (AS-ME). Educating patients, families, and caregivers about asthma including such topics as how to correctly use asthma medications and what to do if asthma symptoms worsen to promote better self-management of asthma. AS-ME incorporates teach-back which is a technique to ensure that medical information is explained clearly so that patients and their families understand what is communicated to them. For examples of AS-ME topics and teach-back, see DHS’s Asthma Care: Your Guide to Managing Asthma, P-02168 (PDF). See the CDC’s Home Visits for Trigger Reduction and Asthma Self-Management Education: Information for Public Health Professionals (PDF) for more on AS-ME.
• Asthma case management. Coordinating with health care providers and providing referrals related to social determinants of health that impact asthma. This can include referrals related to health care, housing, food insecurity, transportation, etc.
• Basic home environmental assessment. Assessing the home environment for common triggers of asthma exacerbations such as cockroaches or mold and provide recommendations for reducing triggers. See the CDC’s Home Visits for Trigger Reduction and Asthma Self-Management Education: Information for Public Health Professionals (PDF) for more on home environmental assessments.
• Household supplies for trigger reduction. Providing families with supplies to reduce asthma triggers in their home environment such as asthma-friendly cleaning kits, mattress and pillow dust mite covers, vacuums with HEPA filters, and more.

The Wisconsin Asthma-Safe Homes Program also provides asthma-related home repairs to eligible clients to address the root cause of asthma triggers in the home environment. This can include removing carpeting that is a reservoir for allergens, installing a kitchen or bathroom exhaust fan to improve indoor air quality, remediating mold, and employing pest control strategies. If this is out of scope for a health plan or health care organization’s home visiting program, organizations could consider partnerships with local agencies that provide housing services in the area.

If during the planning process the health plan or health care organization determines it is not yet able to provide asthma home visiting services but could provide in-clinic or virtual visits with patients to provide asthma self-management education, this component could be adapted for those settings. While there are major benefits to providing asthma education in the home setting, the delivery of asthma-self management education across settings can improve patient outcomes. Assessment of the home environment should be part of asthma self-management education even if not conducted in the home to identify and provide recommendations to reduce environmental asthma triggers. In addition to asking patients questions about their home environment to complete an assessment, organizations can consider conducting virtual assessments.

How many visits will be provided?

Depending on the components of the home visiting program and staff capacity, health plans or health care organizations will have to determine the number of home visits and potential follow-ups they will provide. Programs can be effective with at least two home visits, but additional visits can yield greater improvements in asthma outcomes for some clients. The Asthma-Safe Homes Program requires at least two home visits but does provide participating organizations the ability to provide additional visits (not all are required to be in-home). Follow-ups are also recommended as an opportunity to check-in on progress with asthma management. The Asthma-Safe Homes Program follows up with clients by phone at 2–weeks and 3–months post-intervention.