National Capital Region Asthma Partnership Conference Workshop Proceedings Summary Report

Submitted by: Elaine Bonneau, B.A.; Heather Evanson, B.A.; Kristin Evans, B.A.; Zivile Ilgauskaite, B.A.; Brook Kearley, M.A.; Jenny Namur-Karp, MPH

Social Solutions International, Inc. 8070 Georgia Avenue, Suite 201 Silver Spring, MD 20910 Phone: 301-774-0897 Fax: 301-570-4772 Submitted to:

Primary Contact: Brook Kearley, M.A. Email: bkearley@socialsolutions.biz Phone: 410.336.8455 Date Submitted: May 19, 2010

TABLE OF CONTENTS
INTRODUCTION ..................................................................................................................................................... 1 OVERVIEW .................................................................................................................................................................1 SECTION 1: IMPLEMENTING AND PROMOTING THE NHLBI GUIDELINES REGIONALLY............................................ 2 Best Practices to Improve Provider Adherence to NIH Guidelines ............................................................................2 Successful Strategies, including Social Marketing Strategies, to Communicate with Providers to Encourage Better Adherence to the NIH Guidelines ..............................................................................................................................2 Barriers to Increasing Adherence to NIH Guidelines .................................................................................................2 Suggestions to Overcoming Adherence Barriers .......................................................................................................3 Ensuring that Health Literacy is Addressed Among Disparate Racial/Ethnic Groups in Dissemination of Asthma Education by Providers ..............................................................................................................................................3 SECTION 2: REGIONAL APPROACHES TO ASTHMA IN THE URBAN ENVIRONMENT AND HEALTHY HOMES ............ 4 Best Practices to Decrease Indoor Environmental Asthma Triggers .........................................................................4 Successful Strategies, including Social Marketing Strategies, to Communicate to Both Clinicians and Consumers About The Importance of Healthy Homes in the Reduction of Asthma Triggers ......................................................4 Barriers to Decreasing Exposure to Indoor Environmental Asthma Triggers ............................................................5 Suggestions to Overcoming Indoor Environmental Asthma Trigger Barriers ............................................................5 Ensuring that we are Addressing the Issue of Asthma and Environmental Triggers in a Culturally Competent Manner ......................................................................................................................................................................5 Suggested Regional Efforts to Decrease Exposure to Indoor Environmental Asthma Triggers in Multiple Settings.6 SECTION 3: IMPLEMENTING AN ASTHMA SOCIAL MARKETING CAMPAIGN THROUGHOUT THE REGION ............... 6 Successful Social Marketing Campaigns: Whats required ........................................................................................6 Cost Effective Resources ............................................................................................................................................6 Barriers to Social Marketing and How to Overcome those Barriers ..........................................................................6 Suggested Regional Efforts to Raise Awareness about Asthma ................................................................................7

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INTRODUCTION OVERVIEW The Maryland Department of Health and Mental Hygiene (DHMH), Family Health Administration, Center for Maternal and Child Health received a grant from the Centers for Disease Control and Prevention (CDC) in 2001 tasking the department with the development of an infrastructure to address asthma, a surveillance system and an asthma control plan. By 2007, based on findings since 2001, the statewide Maryland Asthma Control Plan was developed and implementation, overseen by the newly formed Maryland Asthma Coalition, was underway. Related to this effort is a current priority to expand the scope of asthma control efforts beyond state borders to look at regional collaboration possibilities. To that end, the State Asthma Control Programs in the District of Columbia (DC) Maryland (MD) and Virginia (VA) State Health Departments partnered to address the burden of asthma within the National Capital region at its first ever conference for regional health professions and community organizations. The National Capital Region Asthma Partnership Conference: Partnering across state lines to address the burden of asthma was held at the Kellogg Conference Center, Gallaudet University, Washington, DC, on May 6, 2010. The all day conference incorporated presentations by the following speakers: Asthma in the National Capital Region - LaVerne Jones, MPH/Linda Nwachukwu, MPH; Collaborating to Put Evidence-based Asthma Care into Action - James P. Kiley, PhD; Putting the NHLBI Guidelines into Practice - Judith Taylor-Fishwick, MSc, AE-C; Asthma and the Home Environment - Janet Phoenix, MD, MPH; Introduction to Social Marketing - Anne, Marie OKeefe, PhD, JD; How the media can help drive new Social Norms to reduce Asthma - Kristy Miller, MA; and Housing and Asthma - Dr. Patrick N. Breysse. The final segment of the conference was comprised of three breakout workshop discussions. These sessions provided participants with an opportunity to select a topic based on their interests on which they could brainstorm regional strategies. The sessions were titled Implementing and Promoting the NHLBI Guidelines Regionally, Regional Approaches to Asthma in the Urban Environment and Healthy Homes, and Implementing an Asthma Social Marketing Campaign throughout the Region. Social Solutions staff facilitated each of the breakout sessions and compiled the main findings to present to conference participants in the closing session. The following report summarizes the findings of conference workshop discussions.

SECTION 1: IMPLEMENTING AND PROMOTING THE NHLBI GUIDELINES REGIONALLY BEST PRACTICES TO IMPROVE PROVIDER ADHERENCE TO NIH GUIDELINES Several participants referenced use of Asthma Action Plans as a strategy to ensure closed circuit communication between healthcare providers, clients and school health systems. Participants stated that streamlined paperwork practices (e.g., combination medication directives for providers and action plans) were important elements in their success. Additionally, practices such as evidence-based toolkits for emergency department staff use with clients including Asthma Diaries, Brochures, Peek-flow Meters, and Management Plans were recommended and discussed. Finally, incorporating prevention and the Asthma Guidelines into health care provider professional development (inclusive of CEUs/CMEs) -especially in rural areas -- was provided as a best practice. SUCCESSFUL STRATEGIES, INCLUDING SOCIAL MARKETING STRATEGIES, TO COMMUNICATE WITH PROVIDERS TO ENCOURAGE BETTER ADHERENCE TO THE NIH GUIDELINES Building upon the concept of professional development training and education as a means to improve adherence, several participants provided strategies that referenced incorporation of guidelines into healthcare provider trainings, including trainings on medication administration. Performing gap analyses and needs assessments to strengthen trainings was also discussed as a successful strategy. Education strategies were prevalent throughout the responses. One participant spoke about a partnership their organization formed with pharmaceutical associations and the University of Maryland, School of Pharmacy to promote asthma education. Other participants discussed Asthma Summits and Annual Asthma Update sessions for health care providers. Strategies to ensure strong lines of communication between hospital physicians, pediatricians, parents and schools were mentioned several times. For example, one participant from an area hospital mentioned that their policy is that attending physicians in the emergency department call a patients pediatrician as part of the Action Plan development process, a copy of the Plan is faxed to the pediatrician, and a lay-person version of the Plan is provided to parents prior to the patients discharge. BARRIERS TO INCREASING ADHERENCE TO NIH GUIDELINES Primary barriers to adherence included lack of communication among the care providers; limited knowledge of guidelines (only one participant in the group had read the guidelines or knew someone who had read the guidelines); lack of time; lack of knowledge about device use and therefore application of guidelines; and defeatist attitudes. Chains of communication and follow-up were mentioned as barriers to completion and implementation of Action Plans. Barriers with physicians and the quality of care they provide were also discussed. Many participants thought that physicians attitudes were a major barrier. Some participants stated that doctors had defeatist attitudes. Others mentioned that physicians dont view their patients as partners and others stated that doctors do not use available tools. All agreed that there are few incentives for physicians to
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control asthma in their patients, especially those who are paid by Medicaid since doctors are not paid based on the good health of their patients. In addition to physician attitudes, participants discussed that many doctors dont know how to use devices themselves and, therefore, do not provide device training to patients. Finally, the barrier of providers not reading the guidelines because the guidelines are long (700 pages) and confusing was discussed. SUGGESTIONS TO OVERCOMING ADHERENCE BARRIERS A number of strategies were suggested to address barriers associated with physicians attitudes. Participants stated that a strong emphasis on personal accountability was needed. To accomplish that, there was discussion regarding pay for performance approaches. While many participants questioned the tactic of linking pay or pay raises to performance, the concept that physicians could lose money for not providing patients correct care was discussed among the participants. Another suggestion was that insurance companies tie quality improvement to their ratings with documentation to back it up. One participant mentioned a strategy adopted by the State of Maine where monthly reports of physician adherence to guidelines were shared with all practice or hospital staff. Public awareness of adherence or lack thereof was believed to improve compliance to the guidelines significantly. In order to address physicians not training patients on devices, the strategy was to assume that health care providers dont know how to use the devices and provide all providers training. To address the barrier of providers not reading the guidelines participants suggested the development of a brief, easy-to-read, streamlined education/refresher tool. Suggested tools included Clinical Pathways, Cheat Sheets, and a video to be posted on the internet. To address missing or incomplete Action Plans, participants suggested providing blank Plans to providers and patients families. ENSURING THAT HEALTH LITERACY IS ADDRESSED AMONG DISPARATE RACIAL/ETHNIC GROUPS IN DISSEMINATION OF ASTHMA EDUCATION BY PROVIDERS Participants affirmed that Health Literacy was a major barrier to providing quality asthma care to clients. In order to address this issue several strategies and practices were provided. While numerous participants mentioned the availability of patient education materials in multiple languages (most frequently Spanish,) many participants discussed the importance of truly low-literacy or no-literacy materials that use racially congruent images to relay important information without relying on language and words. Another participant discussed the idea that cultural competency be included in the Certified Asthma Educator training. A participant from a Virginia hospital referenced software that allows Action Plans to be developed in English and then printed in other languages. Finally one participant discussed a new event, a Dinner with the Doc program that provides clients with an opportunity to have dinner with a physician in order to discuss asthma issues. The unique component of the event is the inclusion of a Health Librarian who attends the dinner in order to study the physicians use of language and communication style to determine the level at which clients are likely understanding and connecting with the providers.

SECTION 2: REGIONAL APPROACHES TO ASTHMA IN THE URBAN ENVIRONMENT AND HEALTHY HOMES BEST PRACTICES TO DECREASE INDOOR ENVIRONMENTAL ASTHMA TRIGGERS Participants brainstormed some best practices used to decrease indoor asthma triggers including promoting polices directed at curbing smoking in cars or homes, not using gas stoves for heating, encouraging people to make sure their homes are roach and pest free by providing pest management services, as well as encouraging and providing resources for people to identify and remedy mold problems. SUCCESSFUL STRATEGIES, INCLUDING SOCIAL MARKETING STRATEGIES, TO COMMUNICATE TO BOTH CLINICIANS AND CONSUMERS ABOUT THE IMPORTANCE OF HEALTHY HOMES IN THE REDUCTION OF ASTHMA TRIGGERS Participants mentioned a variety of strategies used in their asthma programs to reduce indoor triggers that ranged from raising awareness to coordinating and providing resources or referrals. Awareness raising strategies involved outreach to the community to provide information. One example was a Family Feud-style game night with information on asthma triggers that was used in the community at high schools, while a similar program used a game called Pin the Tail on the Pollutant at a public market in Baltimore. Another participant mentioned an outdoor school program with an asthma curriculum designed for both the general student body as well as specific components for students living with asthma. Using visuals with English as a Second Language (ESL) populations was mentioned as an alternative method for community outreach. An example was given of a program that used the EPA diagram of asthma triggers in the home to health care provider waiting rooms. Additionally, two participants described a program called Asthma Friendly Schools in Maryland which provides schools with technical support and evaluation to reduce triggers in the school environment and provides resources on needed changes to improve asthma outcomes. Several health care related strategies were also discussed among the group as ways to reach patients and providers. One participant explained that some healthcare insurers provide telephone case management to people with asthma. Two group members described a program at a hospital in Maryland where they created a role for and hired an asthma case coordinator who has face-to-face contact with asthma patients, works with them on ensuring development of an action plan before discharge, and provides referrals. A recent evaluation of this program showed that it increased the percentage of asthma patients with an action plan at discharge to over 90%. The family and community medicine residency program at University of Maryland was mentioned as prioritizing asthma action plans for children who visit the emergency room. In this program, before patients are discharged, residents help them develop a plan and provide them with three copies one to have at home, one at school, and one on file at the patients primary physicians office.

Additional strategies discussed included providing the community with resources. One program mentioned is assisting residents of homes where there are pollutants, mold, pests, etc., by writing to landlords to get them to make necessary improvements and provide referrals for housing and resources. Another had a community provider who would go to the homes of people with asthma and teach them how to properly clean to minimize pollutants and other asthma triggers in their home environment. BARRIERS TO DECREASING EXPOSURE TO INDOOR ENVIRONMENTAL ASTHMA TRIGGERS Many barriers to decreasing indoor exposure were highlighted by participants. Barriers included private landlords who do not necessarily comply with requirements, and residents, especially those with tentative legal status, who are less likely to raise issues with the landlord or authorities. Another substantial barrier discussed widely among the participants was the large paperwork burden for children to keep their medications at school. This burden is on both the family and the physicians who have limited time. One barrier to effective case management mentioned by a participant was telephone case management because it was perceived as not as effective for asthma patients as in person case management. Additionally, participants perceived a gap in knowledge and awareness around asthma issues, which make behavior change challenging. Another challenge mentioned was program sustainability and how loss of funding or lack of funding inhibits the efforts of asthma programs. SUGGESTIONS TO OVERCOMING INDOOR ENVIRONMENTAL ASTHMA TRIGGER BARRIERS One suggestion for overcoming barriers was to streamline the process for students to take inhalers and other asthma medications to school and pushing the school to raise awareness about the importance of having medications onsite. Another suggestion was finding ways to improve sustainability by finding funding for programs and resources through state and local government reimbursements. Finally, educating health care providers on best practices and development of action plans though residency programs and ongoing professional trainings was mentioned as a great opportunity to increase awareness and resources. ENSURING THAT WE ARE ADDRESSING THE ISSUE OF ASTHMA AND ENVIRONMENTAL TRIGGERS IN A CULTURALLY COMPETENT MANNER Utilizing and having access to interpreters and having resources in multiple languages were mentioned by several group members as key to cultural competency. One way group members discussed accessing interpreters, if program staff are not bilingual, was to utilize a broader network of organizations or volunteers that can provide those skills. Some participants offered the services of their own employees to the larger group. Additionally, participants mentioned taking advantage of existing programs that are for specific populations, for example, a DHHS program for native Spanish speaker that works with landlords to make necessary improvements.

SUGGESTED REGIONAL EFFORTS TO DECREASE EXPOSURE TO INDOOR ENVIRONMENTAL ASTHMA TRIGGERS IN MULTIPLE SETTINGS Participants came up with the idea of creating a coalition to share resources. As this concept developed, most group members expressed interest in being at the table. One participant, from EPA offices in Philadelphia, offered to host the quarterly lunch conference call/webinar. Topics for the meetings will be driven by group interest and can be presented by group members or guests. This coalition will begin with a listserv to share resources, events or ask questions. SECTION 3: IMPLEMENTING AN ASTHMA SOCIAL MARKETING CAMPAIGN THROUGHOUT THE REGION SUCCESSFUL SOCIAL MARKETING CAMPAIGNS: WHATS REQUIRED Getting to know the community you want to reach before developing your message and strategy was mentioned as the first step and most important factor in developing successful social marketing campaigns. Additional components of a successful campaign discussed included: getting the community involved in campaign development (allowing them to guide you on effective ways to create the motivation to act); recognizing that the messenger is as important as the message (finding individuals or character representations that the audience can identify with and relate to, e.g., DC Tobacco Free Families partnered with Darryl Green, a recognized figure in the community who was able to make the connection and incite people to act); keeping the strategy localized and collaborating regionally; working with community organizations that already have established trust and reputation within the community to reach their constituents (looking for synergy in your respective missions to identify opportunities for collaboration); and utilizing referrals (family, friends). Specific examples of successful social marketing campaigns discussed included: Click it or Ticket; No Phone Zone; Truth Campaign; DC Tobacco Free Families. COST EFFECTIVE RESOURCES Participants had several suggestions for making resources cost effective. One suggestion was communication on regional, local and national levels in order to leverage resources of work done by other agencies, such as the communications tools offered free of charge from the EPA, which can be localized and applied to multiple communications platforms such as TV, radio, social networks, etc., e.g., CDC, DOH, EPA, IAI. Another participant mentioned improving communication and coordination between neighboring regional programs, i.e. DC should know when MD is running TV or a widespread campaign, and vice versa, to maximize impact and reduce overlapping efforts as a means to improve cost effectiveness of efforts. One participant suggested involving healthcare providers, families and friends to increase word of mouth referrals. Additionally, developing and implementing faith-based interventions was discussed because they can utilize the voice and influence of faith-based communities to continue outreach when social marketing dollars are limited or expended. BARRIERS TO SOCIAL MARKETING AND HOW TO OVERCOME THOSE BARRIERS There were several barriers identified by participants including cost (media costs, production, staff time), need for referrals for providers, and complacency with the prevalence of asthma. While no specific strategies for overcoming those barriers were suggested, methods to overcome other barriers were discussed and follow below.
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To address the lack of asthma educators, participants mentioned the need to implement changes in Medicare/Medicaid which currently requires a signature by a certified asthma educator for approval. Compelling all providers to complete an action plan may necessitate policy changes. Participants also mentioned the need to provide training for staff so they can address asthma messages in informative and culturally sensitive ways. Another suggestion for diminishing racial disparities was developing messages that are culturally sensitive and appropriate (e.g., DCs new Latino Novella campaign cited as an example of using a cultural affinity for TV novellas to tell the story of asthma suffers). Additionally, the importance of knowing the target audience and developing the right tools and using the right mediums for them is essential. For example, utilizing a multi-pronged approach to asthma awareness will be most effective including website for free CMEs, monthly trainings to increase guideline implementation and provider referral; videos/educational tools for different ages (Wees World for kids and So You Think You Have Asthma for teens cited as examples); asthma education packets for family practice (VA Medical Society cited as an example). SUGGESTED REGIONAL EFFORTS TO RAISE AWARENESS ABOUT ASTHMA Several awareness raising ideas were developed for a regional effort. One idea was to create a repository of asthma resources (digital library that everyone on local, regional levels can access and share resources) that might be an intranet or housed on a public site. Another idea was to have call-in numbers (including 1-800 numbers) localized for better measurement and tracking. Another suggestion was having a consumer driven campaign. To raise awareness and reduce stigma, one suggestion was to incorporate culturally sensitive videos about asthma management. A larger scale concept to improve regional efforts was to form an asthma subcommittee of the Regional Capital Partnership to create a regional self efficacy and self management social marketing plan. This subcommittee would allow for information sharing, including resources and best practices and would facilitate looking for synergies in regional asthma efforts, as well as other public health organizations whose missions are supported by asthma outreach, i.e., tobacco cessation, childhood obesity. The group actually scheduled the subcommittees first meeting to be held during the 1st week of June. Finally, participants discussed utilization of media and PSA opportunities. Participants thought that creating PR calendars for the media to let them know whats going on in local organizations would increase press hits and free media exposure that coincide with regional social marketing campaigns. This strategy was believed to maximize awareness efforts in a well-orchestrated way.