PCORI funds Dissemination and Implementation projects to increase awareness and promote the use of PCORI research findings to improve healthcare practices and health outcomes. This project is proposing to conduct dissemination and implementation activities for the results of the research project: Guidelines to Practice (G2P): Reducing Asthma Health Disparities through Guideline Implementation.
1. What research finding is this project disseminating or implementing?
Public Health – Seattle and King County (PHSKC), in partnership with local health clinics, two Medicaid health plans, and other health experts, implemented a two-year, multi-sector clinical trial to assess the comparative effectiveness of an integrated a community health worker (CHW) and enhanced asthma clinic intervention. The first component included a CHW home visit intervention that consisted of three home visits. Secondly, an enhanced asthma clinic intervention with CHW/practice team system integration provided high quality planned asthma care with a variety of quality improvement tools, training, and support.
The CHW home visitor intervention demonstrated a significant change in every outcome studied, and most changes remained significant after statistically correcting for multiple comparisons. Based on the final model, there was a significant CHW intervention effect on asthma symptom-free days, Asthma Control Test (ACT) score, and asthma-related quality of life score. The CHW intervention effect was also significant on five secondary outcome measures, including nocturnal wakening nights, urgent care utilization, oral steroid use, and missed work or school days. This dissemination and implementation project intends to translate the model for widespread use in Washington State. To ensure success and sustainability, it will be adapted to ensure that when implemented throughout the state it is responsive to the cultural and linguistic norms of the community of focus.
2. Why is this research finding important?
Health and healthcare disparities are pervasive across the United States, in particular for people of color, immigrants, and low-income individuals. It directly and indirectly influences their asthma morbidity. Providing the right clinical assessment and treatment at the right time is essential to asthma management. This CHW model proved to be an effective, culturally competent approach to helping people with asthma understand the root causes leading to uncontrolled asthma, acquire the skills they need to control asthma, and resulted in improved health outcomes and quality of life. It also improved care processes that allowed clinical providers to better address patients’ asthma via integration of CHWs into the care team.
3. What is the goal of the D&I project?
The intention of this project is to translate the success of the original project to scale in multiple communities throughout Washington State. The model will be adapted and tailored to meet both the needs of the implementing organizations and the communities that they serve.
Aim 1: Scale-up the evidence-based asthma community health worker home visiting program in four regions of Washington State, to reach approximately 1,700 low-income people between 5 and 64 years with poorly controlled asthma over the two-year PCORI funding period, and ultimately an estimated 3,800 patients over the four-year intervention period of the Medicaid Waiver.
Aim 2: Increase adaptability and sustainability by tailoring existing CHW trainings to be applicable for all levels of organizational and/or CHW readiness. This includes a manager-training program for those who will be mentoring the CHWs through ongoing learning, self-care strategies, onboarding new CHW staff, building partnerships, and other supports; and a multimedia interactive online tutorial for asthma-focused CHWs to use as a foundational component of their learning, as well as hands-on training.
Aim 3: Evaluate the scaled-up program using the RE-AIM model’s framework: Reach, Effectiveness, Adoption, Implementation, and Maintenance.
4. What is the project team doing?
The research and implementation team includes academic clinician researchers, evaluators, public health program managers, CHWs, patients, MCOs, and clinical network representatives. Training participants include CHWs, managers providing supervision of CHWs, and clinical practice teams. In-person trainings will be coordinated regionally as well as the development of a multimedia, interactive tutorial for CHWs, in order to ensure accessibility for each participating ACH. Community Advisory Board (CAB) meetings and support for program implementers will be webinar-based.
5. How will the project team evaluate its D&I activities?
Evaluation of this project will utilize a RE-AIM framework as it provides a practical approach for evaluating programs within a real-world setting. It balances internal and external validity and addresses considerations relevant to dissemination, implementation, and scale up. It is also compatible with socioecological models of health and is useful for evaluating the public health impact of multilevel, multicomponent programs similar to this intervention. The measurement period will be 12 months, quarters 2 through 8. Project outcomes will incorporate the following:
Reach will be assessed as the absolute number, proportion, and representativeness of Medicaid patients (ages 5 to 65) with severe, uncontrolled asthma visited by a CHW.
Effectiveness will be assessed in terms of patient-reported symptom-free days, hospitalization and ED use, rescue medication use, missed work or school, and self-rated asthma control over the past four weeks.
Adoption will be assessed as the absolute number and proportion of CHWs trained in the home visit program and making asthma-related home visits.
Implementation will be assessed in terms of program fidelity, number of home visits, number of new referral pathways established during the program, and facilitators, barriers, and adaptations to program delivery.
Maintenance will be assessed as the absolute number and proportion of trained CHWs retained as CHWs by ACHs and making an asthma-related home visit at 12 months post-training.
6. How is the project team involving patients and others in this D&I project?
Success of this project is dependent on establishing authentic engagement, clear communication, and shared leadership with patients and other stakeholders as they will be guiding and helping the research team shape the development of this effort, expand its reach, and secure its sustainability. We will convene a regional Community Advisory Board (CAB) that is representative of regional ACH organizations, CHWs, community members, patients, providers, the Washington Department of Health CHW Program, and MCOs. It will also include partners who were involved in the original PCORI G2P study. The CAB will provide the necessary diversity of experiences and expertise that will enable adaptation within local contexts and improve the training program design and the support structures needed. They will also provide invaluable feedback regarding implementation challenges and opportunities for continued dissemination of this model.
7. How will this project help ensure future uptake and use of PCORI results?
This effort is well positioned to affect healthcare delivery and policy development throughout the state. The healthcare landscape in Washington State is experiencing a transformation as result of CMS approval of its 1115 Medicaid Waiver project. All Accountable Communities of Health (ACH) throughout the state selected chronic disease prevention and control as one of the focus areas in their waiver projects. A majority of them included community-based asthma management as a strategy. In addition, the state’s ability to meet various waiver-related health metrics is impacted by each ACH region meeting their benchmarks. As a result, they each selected a plan to employ CHWs focused on asthma and chronic disease management in some capacity. The state requires waiver projects to utilize evidence-based models, making our CHW model a good fit for many ACH communities. Moreover, part of the transformation includes testing a value-based payment model for CHW services. By inserting the spread of a proven CHW asthma home visit model into this Medicaid transformation effort, it will allow the waiver to transform how these services are sustainably reimbursed through a value-based payment model.
Learn more about PCORI’s Dissemination and Implementation program here.