Community-Based Care Coordination

Abstract

Care coordination programs have been used to address chronic illnesses, including childhood asthma, but primarily via practice-based models. An alternative approach employs community-based care coordinators who bridge gaps between families, health care providers, and support services. Merck Childhood Asthma Network, Inc. (MCAN) sites developed community-based care coordination approaches for childhood asthma. Using a community-based care coordination logic model, programs at each site are described along with program operational statistics. Four sites used three to four community health workers (CHWs) to provide care coordination, whereas one site used five school-based asthma nurses. This school-based site had the highest caseload (82.5 per year), but program duration was 3 months with 4 calls or visits. Other sites averaged fewer cases (35 to 61 per CHW per year), but families received more (7 to 17) calls or visits over a year. Retention was 43% to 93% at 6 months and 24% to 75% at 12 months. Pre-post cross-site data document changes in asthma management behaviors and outcomes. After program participation, 93% to 100% of caregivers had confidence in controlling their child's asthma, 85% to 92% had taken steps to reduce triggers, 69% to 100% had obtained an asthma action plan, and 46% to 100% of those with moderate to severe asthma reported appropriate use of controller medication. Emergency department visits for asthma decreased by 36% to 63%, and asthma-related hospitalizations declined by 26% to 78%. More than three fourths had fewer school absences. In conclusion, MCAN community-based care coordination programs improved management behaviors and decreased morbidity across all sites.

Community Health Workers as Support for Sickle Cell Care

“…52,60–63 For children with chronic disease, evidence of the benefit of CHWs is particularly strong for asthma. 44,64–66 In addition, studies indicate that CHW interventions are cost effective, especially when taking a longitudinal view of the return on investment. 54,67–71 CHW interventions have specifically been shown to lower hospital readmissions.…”

Study protocol for a randomized controlled trial to assess the feasibility of an open label intervention to improve hydroxyurea adherence in youth with sickle cell disease

“…As in Columbia’s asthma treatment study [55, 56, 81], CHWs will be supervised jointly by CLOTH personnel (administrative/employment) and by the study PIs (program). PIs will meet with CHWs bi-weekly, and ad hoc as needed, to review: forms, cases, automated text messaging reports, information on SCD, and tailoring of the intervention based on dyad needs and age/developmental stage of the youth.…”

“…CHW integration with the health team was successfully integrated into asthma care for young underserved children and decreased hospital admissions and other morbidities by 42–63% [55, 56]. Subjects for the asthma intervention, primarily young children and their parents, were identified at the time of an emergency room visit for asthma exacerbation.…”

Evaluation of a Pilot Asthma Care Program for Electronic Communication between School Health and a Healthcare System’s Electronic Medical Record

“…School nurses are in a unique position to close gaps in care for school-aged children who have experienced a recent asthma exacerbation that resulted in a hospitalization. Activities within the scope of a school nurse's practice include providing healthcare and education to students and staff, performing health screenings, and care coordination with the medical home or private health care provider [13,14]. Care coordination involves intentionally organizing patient care activities and sharing information among all of the participants concerned with a patient's care to achieve safer and more effective care, which can include activities in transitions of care and post care follow up, support of self-management and communicating on behalf of the patient to care team [15].…”

“…Electronic HIEs allow doctors, nurses, pharmacists, other health care providers, and patients to appropriately access and securely share vital medical information electronically, improving the speed, quality, safety, and cost of patient care. They can increase the completeness of patients' records and avoid readmissions, errors, and duplication [14]. Several states and private healthcare facilities are working on establish-ing such exchanges, which will not depend on the use of one EMR vendor, but translate data in a way that allows authorized parties across different systems to read and contribute to patient records.…”