Asthma is as indigenous to the Bronx as malaria is to sub-Saharan Africa. The Bronx’s asthma death rates are three times higher than the United States’ average, with hospitalization rates for the borough soaring even higher. Double the number of children with asthma live in certain sections of the Bronx than in areas only a few subway stops away in Queens and Manhattan.
And, it’s a leading reason for why the Bronx, for nearly a decade, has maintained a death grip on 62nd and last place in the state when it comes to health outcomes.
Healthy Buildings Project
In 2017-18, BPHC and the Northwest Bronx Community & Clergy Coalition (NWBCCC) introduced the Bronx Healthy Buildings Program, with the intent of “holistically addressing the root causes of morbidity among asthma patients and reducing asthma-related emergency room visits and hospitalizations.”
Beginning with home visits that involved educating residents on proper medication use, the program quickly expanded.
“The point is asthma is an environmental epidemic, and out of 100 patients we would call on, we would only get into the homes of 30,” says Dr. Moon. “Our overall success rate was 38 percent, at a cost of $2.6 million. That was not good enough.”
Adds Bronte Kastenberg, project manager of clinical improvement projects at BPHC, “Someone can have an ED visit and go get their inhaler and all their medications, but if they are coming home, where the paint is peeling off the walls and there is mold, then the medication is only going to do so much.”
This meant a transition towards a population-oriented and place-based engagement strategy that resulted in outreach to 35 buildings (including NYCHA public housing) with high rates of asthma-related emergency room visits and hospitalizations and high rates of building code violations. Landlords in these buildings were required to make capital improvements (from new boilers to new windows), which included cost-effective, energy efficient and health upgrades, air quality improvements and general structural repairs. Home-based asthma interventions were initiated, tenant leaders were trained in social determinants of health, and pest management contracts were secured. Asthma resources were diversified by increasing partnerships, such as with a community health network to train homecare attendants and community pharmacies to deliver medicines and educate recipients. An app, RxHealth, was deployed to enhance the interaction between PCPs and their patients.
Pre-intervention surveys found that among residents of these buildings:
- 43 percent of adults and 25 of children had asthma
- 24 percent of adults and 18 percent of children had asthma attacks in the last year
- 14 percent of adults and 4 percent of children were hospitalized for asthma-related attacks
- 16 percent of adult residents and 8 percent of children went to the ER with asthma-related attacks
A majority of surveyed patients reported being dissatisfied with their housing conditions, which was not surprising in that 52 percent reported water leaks; 58 percent complained of mold and mildew; 73 percent had problems with poor rat control services; and 74 percent had issues with poor cockroach control services.
Pilot findings for the healthy buildings project have been nothing short of amazing. Within the purview of patients seen at SBH during this 2018 period, it was found that ED visits fell 75% post- intervention and the rate of ED visits per asthmatic patient (average number of visits per patient) fell 100% (from 1.34 visits per patient to 0.34 visits per patient).
The Changing Role at SBH
In its pursuit of becoming an asthma center of excellence, SBH has doubled down on making changes to heighten patient accessibility and fill in much-needed gaps in care.
“I am working very closely with SBH on a project aimed specifically at reducing potentially preventable emergency department visits (PPV),” says Dr. Amanda Ascher, Chief Medical Officer at BPHC. “Together, as a group, we looked at a list of state reported PPV and found that over 90 percent of them were asthma related. Now, I am working with the emergency department and the ambulatory folks on how to target the asthmatics better. How can we make sure everyone has an asthma action plan? Are vaccines up to date? Has tobacco counseling been addressed? How can we make sure every one of our highest risk patients has a nebulizer at home?
The hospital, as a result, has developed a “bundle” of measures to move forward on. This includes immunizing patients to prevent exacerbations; making sure patients have an action plan so they can better manage their disease; getting smokers to stop smoking; encouraging the use of digital resources like RxHealth; and making sure those with very severe or atypical asthma have access to special medicines (such as biologic therapy). Resources like community pharmacies and paramedics are now part of the overall care equation.
“Because asthma is such a prevalent condition in our community, we see a lot of people in primary care who not only have asthma as their only diagnosis, but as a constellation of a variety of different illnesses,” says Dr. Gurunathan. “In the primary care setting, it is our job to try and identify and make sure people are getting very basic preventative care and health maintenance that is related to having asthma, and also identify those people who would benefit from, say, extra pulmonary support.”
Much of this comes down to changing processes, so asthmatics won’t fall through the cracks.
“Take the case of the patient who had a nebulizer prescribed by our PCP and then went to her pharmacy to fill the prescription, only to find the pharmacy doesn’t dispense them,” says Dr. Ascher. “So the patient, without a nebulizer, ends up back in the ER. Now, with that patient referred to community paramedics, who fixed the problem, everything has worked out to keep her out of the ER.”
On a practical scale, according to Dr. Raghu Loganathan, Director, Division of ICU and Pulmonary Medicine, adults and children now have access to same day appointment. A pulmonologist sees all asthmatics coming through the emergency department or admitted to the hospital. A special program is focused around the high risk, high utilizers of services. To eliminate gaps in care, patient navigators provide outreach to make sure they get referred to the necessary services.
Adds Dr. Loganathan, “We take it very personally now if a patient ends up in the ER or needs to be hospitalized.”