pierce county healthy homes case study...website: © 2019 washington state university energy program...

Washington State Weatherization Plus Health Program Pilot

Pierce County Healthy Homes Case Study

January 2019

Website: www.energy.wsu.edu

© 2019 Washington State University Energy Program905 Plum Street SE, P.O. Box 43165Olympia, Washington 98504-3165

WSUEP19-003 • January 2019

PierceCountyHealthyHomesCaseStudy

PierceCountyHealthyHomes(PCHH)Partnership–withWeatherizationPlusHealth(Wx+H)programfunding–deliveredintegratedhealthyhomesservicesincludingCommunityHealthWorker(CHW)engagementandhomevisits,energyefficiencyandhealthyhomesupgradesto53lowincomehouseholdswith78occupantswithrespiratoryhealthconcerns–suchasasthmaandChronicObstructivePulmonaryDisease(COPD).Ashighlightedinthesidebar,initialresultsshowpromisingsuccessinencouragingactionandimprovingthehealthandqualityoflifeofclientswithrespiratorydisease.

PCHHisapartnershipcomprisedofPierceCountyHumanServices(PCHS)andtheTacoma‐PierceCountyHealthDepartment(HealthDepartment).PCHSisoneofeightlocalpublicweatherizationagenciesintheStateofWashingtontoreceiveanEnhancedWx+HGrantin2016.TheWx+HProgram–fundedbytheStateofWashingtonEnergyMatchmakerProgram–supportspilotprojectstodevelop,test,anddeploynewmeasures,tointegrateinvestmentsinenergyefficiencyandhealthforlow‐incomehouseholdswitheducationandservices.1

Background

BeforereceivingWx+Hfunds,thePCHHpartnershipexistedasanextensionofadecade‐longcollaborationbetweenPCHSandtheCleanAirforKidsPartnership(CAFK–ledbytheHealthDepartment)toofferholistic,integratedservices,inadditiontoweatherizationandminorhomerepair,toimproveasthmacontrolandqualityoflife,whilereducingenergycosts.

Originally,Wx+HfundingwasintendedtosupplementtheCAFKstaffingresources.However,theCAFKpublichealthfundingdrasticallydecreasedjustastheWx+Hprogramwasbeginning.Wx+HfundingwasimportantinallowingtheHealthDepartmenttocontinueofferingasthmahomevisits.Thefocusofthe

initiativeshiftedtointegratingtheCAFKreferralnetworkandasthmahomevisitswithPCHSexistingweatherizationandhomerepairprograms.WhiletheCAFKfocuswasonchildrenwithasthma,thenewpartnershipbetweenPCHSandtheHealthDepartmentexpandedtoserveallageswithrespiratorydisease–

includingadultswithasthmaorCOPD.

1SeeTheWashingtonStateWeatherizationPlusHealthPilot:ImplementationandLessonsLearned(2018)foracompletediscussion.http://www.energy.wsu.edu/documents/WxHSummaryReport.pdf

InitialPromisingHealthImpacts

TakingAction:86%ofhouseholdsgettingfollow‐uphomeassessmentsreportedtaking

twoormoreactionstoreduceenvironmentaltriggersorimprovemedicalmanagement

RespiratoryControl:65%reported

improvement(47%reportedasignificantimprovementinACTscores).Thepercentageof

thosewithrespiratoryconditionsundercontrolincreasedfrom42%to67%

QualityofLife:70%reportedanimprovement

inQualityofLifeasmeasuredbyAQLQandCCQ(38%ofimprovementsweresignificant)

FewerMedicalVisits:Oneyearafterinitialserviceswereprovided,studyparticipants

reportedfourfewerUrgentCarevisits,fifteenfewerEmergencyRoomvisitsandsixfewer

hospitaladmissions


ProgramandServiceDeliveryModel

TheinitialstrategyofrelyingheavilyonHealthDepartmentCHWsforreferralsandpre‐qualificationwasadjustedtofocusonexistingPCHSclients–especiallythosereceivingweatherization,energyassistance,andEarlyChildhoodEducationandAssistanceProgram(HeadStart)services.Thiswassupplementedbyjointoutreacheventsandworkwithclinicsservinglow‐incomehouseholds.

PCHSinitiatedtheprocesswithapre‐auditscreeningvisittohomesofallreferralsduringwhichPCHSassessedlikelyeligibilityfor,andinterestin,Wx+Hservices.Theinitialvisitincludedawalk‐throughforahealthyhomesassessment,informationonweatherizationservices,anddiscussionofenvironmentaltriggersandairqualityinthehome.Oncompletionofthepre‐audit,PCHSreferredpotentialWx+HclientstoCHWs.TheCHWthenprovidedonetothreehomevisitsfocusedonasthmaorrespiratoryhealthmanagement,comprehensiveassessmentofotherneeds,anddevelopmentofanactionplan.IfclientshadnotalreadyappliedforWx+Hservices,aCHWassistedwiththeapplication.AsillustratedinFigure1,weatherizationandCHWservicesweredeliveredconcurrently.DuringthegrantperiodHealthDepartmentandPCHSoutreachandauditingstaffmetweeklytoshareinformationandcoordinateservices.TheseinformalsystemswereveryhelpfulintheabsenceofestablishedsystemstoshareinformationonweatherizationprojectandCHWservicestatusandschedules2.

Figure1.KeyStepsintheProcessandAverageMonthsElapsedBetweenEachPhase

Onaverage,fivemonths(range1to14months)elapsedbetweenCHWassessmentsandcompletionofweatherizationhealthyhomesinstallationwork.Thiswaslongerthanexpectedandcreatedchallengesformaintainingclientengagementduringcontractingandinstallation.

2SeePierceCountyHealthyHomesWeatherizationPlusHealthGranteeProfileformoredetailsontheprogramhttp://www.energy.wsu.edu/documents/WxHEnhancedProfilePierce_12‐20‐17.pdf

2months

PCHS• Intake–PreAudit• Referral

TPCHealthDepartment• CHWVisits

PCHS• Audit• EnergyEd• Installation

TPCHealthDepartment• Follow‐UpVisits

5months

12months

9months


Table1.ServicesOfferedbyPCHSanditsPartners

ServicePierceCountyHumanServices

Tacoma‐PierceCountyHealthDept.

PugetSoundAsthmaCoalitionPartners

Outreachandreferrals X x xIntake–screening,qualification X x InitialHealthyHomesAssessment X x Energyaudit/assessment X Servicecoordination X X Medicalsupportandmanagement X XWeatherization X Healthyhomesmeasures X x Clienteducation/follow‐up X X Additionalservices(repair,social) X x XLEAD=X,Support=x,Greenshadingindicatesnewpartnerorexistingpartnerinanewrole

CHWswereexpectedtofollow‐upwithclientsinpersonorbyphoneatthree,nineandtwelvemonthsafter

thecontractedworkwascompleted.Follow‐upcontactsincludedactionplanreview,casemanagementservices,anddatacollectiononhealthconditionsandneeds.Duetoanine‐monthgapinfunding3,mostthreeandninemonthfollow‐upvisitswerenotcompleted.Whenfundingwasrestored,theHealth

Departmentfocusedoncompletingatleastonefollow‐uphomevisitorcalltoeachhouseholdintheninetotwelvemonthperiodafterfinalmeasureinstallation.Householdswithfollow‐upsatlessthansixmonthswereexcludedfromtheanalysis.

ClientandProjectProfiles

PCHSprovidedWx+Hmeasuresandservicesto53householdswith78personswithrespiratoryconditions.Ofthese,40receivedcomprehensiveweatherizationand/orhealthyhomesmeasuresand13received

educationalvisitsandlow‐costmeasures(under$1000),suchasgreencleaningkits,dustmitecovers,andwalk‐offmats.Aprofileofmeasuresinstalledisincludedasanattachment.SeetableA1.

Fiveofthe53PCHScomprehensivehouseholdsdidnotreceiveCHWvisitsbecauseserviceswereprovided

beforethecontractwiththeHealthDepartmentwasinplaceorWx+Hmeasureswerecompletedduringthefundinggap.

ThefinalPCHHPartnershipdatasetincludes48householdsand73personswithrespiratoryconditions.Of73personsserved,29%werereferredforCOPDand71%forasthma.AllofthepersonswithCOPDwere

adults,andofthe52personsreferredforasthma,20(38%)wereadults.ThisrepresentedasignificantchangefromtheHealthDepartment’spreviousworkwhichfocusedonchildrenwithasthma.

Ofthe48householdsreceivingservices,morethansevenintenresidedinmanufacturedhomesandmorethaneightintenownedtheirhome.ClientsreferredtotheprogramwithCOPDweremorelikelytoreceive

comprehensiveservices–inpartbecausetheywerelesslikelytoberentersandthusmoreeasilyqualified

3Wx+HisfundedaspartofWashington’sCapitalBudget.TheFY2018–2019CapitalBudgetwasheldupforninemonths,duetoanunrelateddisagreement.Thisgapoccurredinthewindowwhenmostfollow‐upvisitswerescheduledtooccur.


forweatherizationservices.COPDclientswerealsomorelikelytoberetiredseniorcitizensordisabled,andcouldmoreeasilyaccommodatethetimecommitmentrequiredtoallowprogramstaffandcontractorsinto

thehome.

ClientsreceivingWx+Hservicesreliedonfivedifferentinsurancesystemsandmorethan15separateinsurers.OnehalfreceivedcoveragethroughMedicaid,31%throughMedicare,16%throughprivateinsurance,5%throughTricare/Veteranssystem,and5%throughDSHSdisability.Oneinfivehadmultiple

coverages–thesearemostlyadultswithasthmaandCOPD.Thiscomplexpayermixmakesitverychallengingtocomprehensivelyassessmedicalutilizationoutcomesortodevelopmedicalsystemreimbursementforweatherizationorhomevisitservices.

Table2.HouseholdandProjectCharacteristics

OccupantsreferredforHouseholds

Asthma COPDN= 48 52 21

BuildingType Manufactured 71% 58% 86%Site‐builtSingleFamily 23% 29% 14%Multi‐Family(2+units) 6% 13% 0%Tenure Owner‐Occupied 83% 63% 100%Rental 17% 37% 0%Intervention EducationLow‐Cost 27% 33% 24%Comprehensive 73% 67% 76%SummaryMedicalAcuity(N) (41) (21)High 21% 76%Moderate 39% 5%Low 39% 19%

Medicalacuityreferstothelikelihoodaclient’shealthconditionorsituationwillrequiremedical

interventions4.Thecomplexrelationshipbetweenthemedicalacuityofclientsandtheintensityofinterventions(treatments)complicateseffortstoestablisharelationshipbetweenintensityoftreatmentandtreatmenteffects.AsTable3indicates,clientswithhighacuitywerenotmorelikelytoreceive

comprehensiveWx+Hservices.Anumberofthehigheracuityclientshadotherbarrierstoservicesuchasmentalhealthissues,homesinextremelypoorrepair,anduncooperativelandlords.Asaresultofthesebarriers,theyreceivedlowcostservicesasanalternative.ThiswasconsistentwiththeHealthDepartment

focusofengagingandreferringallclientstoadditionalservicesinordertobuildrelationships,encourageclientstothenextactionstep,refertootherservices,andperhapseventualcompletion.

4TheHealthDepartmentassessedtheoverallmedicalacuityofclientsbasedonoverallresponsesduringintakeandclassifiedclientsaslowacuity(nominorco‐morbidconditionsandadequateorgoodcontrol),moderateacuity(oneseriousco‐morbidconditionand/orpoorcontrolofrespiratorycondition)ANDhighacuity(multipleco‐morbidcondition–respiratoryconditionverypoorlycontrolled).


Table3.TypesofMeasuresandClientAcuity

HighAcuity ModerateAcuity LowAcuityComprehensive 64% 94% 85%LowCost 36% 6% 15%

InitialCHWRecommendations

AcomprehensivereviewofenvironmentaltriggersandmedicalmanagementofrespiratoryconditionswerecorecomponentsofCHWservices.CHWsworkedwiththefamiliestodevelopagreeduponactionsand

strategiestoimprovehealth5.AsshowninTable4,morethanteninitialactionrecommendationswereidentifiedforeachclient.Otherkeyfindings:

• MorerecommendationsweremadeforCOPDclientsandadultswithasthma,thanchildrenwithasthma,inpartbecauseofhigheracuitylevels.

• Nineintenclients(88%)hadrecommendationsinvolvingfollow‐upwithamedicalprovidertoscheduleappointments,createanactionplanortoadjustmedications.Onehalfhad(48%)additionalrecommendationsonhowtobettermanageoruseexistingmedications–suchasproper

useofspacersormasks–orhowtousecontrolmedicationmoreeffectively.ThishighlightstheuniquerolethatCHWscanplayinsupplementingweatherizationservicesbyprovidinganenvironmentalassessment,asthmaandCOPDeducation,motivationalinterviewingandfollow‐up

servicestoencouragebehaviorchange.

Table4.RecommendationsforActionbyReferredClient

5Thisdatareflectsrecommendationsmadeatinitialintake.Additionalactionsandrecommendationsmaybeidentifiedduringfollow‐upvisits.


Follow‐upVisitsandCalls

Follow‐uphomevisitsorphoneinterviewswereconductedwith35householdsandincluded47personswithrespiratoryconditions.Ofthe26clientswhodidnotreceiveafollow‐upcontactbyhomevisitorphone:

• Tenhadmoved

• Fourhaddied• Twowerehospitalized• Fourwerenotcontactedbecauseofsafetyissuesorotherwiserefused

• Sixcouldnotbecontactedorscheduledforotherreasons

Follow‐updatacollectionwasmorelikelytobecompletedforhealthierpersons(loweracuity),morestablehouseholds,andhouseholdsthatreceivedcomprehensiveratherthanlowercostservices.Oneofthechallengesofthisworkisthatthehighestneedshouseholdsareoftenmoremedicallyfragile,lessstable

(morelikelytomove),andoftenhardertoreachwithbehavioralinterventions.Mosthomesthatreceivecomprehensivemeasuresarelikelytoremaininlowincomehousingstockandtheenergyefficiencybenefitswilllikelycontinuetoaccruetolowincomehouseholds.Theturnoverinoccupantswithrespiratory

concernsthatwerespecificallytargetedforassistancesuggeststhatthemedicalcostutilizationbenefitsassociatedwithstructuralorbuildingtargetedinvestmentsmaybelesscertainandpersistentthaninvestmentsforindividualsinbehaviorandpractice–whicharemoreportable.Asthesehomesarealso

likelytoremaininlow‐incomehousingstock,andlow‐incomepersonsarelikelytobemedicallyvulnerable–improvedairqualityandtemperatureregulationislikelytoconferbenefitstofuturelow‐incomeoccupants.Thisischallengingtomeasuredirectly.

Follow‐upassessmentswerecompletedforthreeoffiveclientsoverall.Theresponserateforthehome

assessmentwasthelowest(42%).ReturnratesforclientquestionnairesvariedbyinstrumentwithresponseratessomewhatlowerforclientswithCOPD.

Table5.ResponseRatesforClientQuestionnaire

Total Asthma COPDPre‐Visits(Clients) 73 52 21ACT/TRACK/CAT(control)(Asthma,ChildUnder4) 45(62%) 32(62%) 13(62%)ACQ/ACQC(Medication‐Medical) 43(59%) 31(60%) 12(57%)AQLQ/CCQ(QualityofLife) 37(51%) 30(58%) 7(33%)HomeAssessment(BehaviorChanges) 31(42%) 24(46%) 7(33%)

EvidenceofActiontoReduceEnvironmentalTriggers

Twenty‐oneof48householdshadfollow‐upvisitsorcallsthatincludedsystematicdatacollectiononhealthyhomesactionsandreductionofenvironmentaltriggers(Table6)6.Eighteen(86%)ofthe21householdsreportedthattheymadetwoormorechangestoreduceenvironmentaltriggers(Table6).

6Itischallengingtocaptureallmeasuresandactionstakenbyclientsaschangesaremadeovertime.Allactionswerenotcaptured,andfundingwasnotavailableforallfollow‐upvisits.Homeassessmentswereconductedbyphoneforsixhouseholdsandchangesmaybelessreliablyorcompletelycaptured.


Actionsandbehaviorchangestoreduceasthmatriggersthatweresupportedwithlowcostmeasures(HEPAvacuums,allergencovers,andgreencleaningkits)weremorelikelytooccurorberecalled.Resultsforsome

changes,suchascleaningcurtainsandblinds,weredifficulttointerpretorcontradictory–whichindicatestherecouldbesomeclientconfusion.Insomehouseholds,positiveactionsinoneareawereoffsetbyactionsorbehaviorsinotherareasthatmayincreaseenvironmentaltriggers.

Table6.HouseholdswithPreandPostHomeAssessmentsReportingActiononRecommendedChangetoReduceEnvironmentalTriggers(Householdn=21)

RecommendedChange Better Worse NoChangeNotApplicable/

NoDataVacuuming(HEPA) 67% 0% 10% 24%MeasureHumidity 48% 5% 24% 29%AllergenCovers 48% 5% 10% 38%GreenCleaning 38% 0% 24% 38%CleaningBlinds/Drapes 38% 14% 10% 38%ReduceScentedProducts 29% 5% 38% 24%ReduceSmoke/VapingExposure 24% 10% 10% 57%AirPurifier(noozone/HEPA) 24% 5% 67% 5%Pets/DanderControl 24% 19% 29% 29%

HealthandQualityofLifeOutcomesMeasurement

TheHealthDepartmentusedmultipleinstrumentstoassesshealthandQualityofLifeoutcomesforasthma

andCOPDclients.Outcomesweremeasuredinthreeareas:

• OverallsymptomcontrolwasmeasuredwiththeTRACKforUnderAge4,AsthmaControlTest(ACT),orCOPDAssessmentTest(CAT)

• ImpactonactivitiesandmedicalsystemutilizationwasmeasuredbytheAsthmaControlQuestions

(ACQ)andAsthmaControlQuestionsforCOPD(ACQC)• QualityofLifewasmeasuredbytheJuniperAsthmaQualityofLifeQuestionnaire(AQLQ),Juniper

PediatricAsthmaCaregiverQualityofLifeQuestionnaire(PACQLQ),andClinicalCOPDQuestionnaire

(CCQ)

SpecificscoreresultsarereportedseparatelyforasthmaandCOPDclientsastheinstrumentsandinterpretationoffindingsdiffer.Forexample,asthmacontrolismeasuredviatheACTwhichisscoredonascaleof0to25–withhigherscoresindicatinggreatercontrol.COPDcontrolismeasuredbytheCATwhich

isscoredfrom40to0–withlowerscoresindicatinggreatercontrol.ChangesofthreepointsintheACTandfivepointsinCATareconsideredsignificant.

AlthoughresultsfromasthmaandCOPDinstrumentsshouldnotbedirectlycompared–itispossibleto

classifywhethercompletedquestionnairesreportedpositiveornegativechanges,andwhetherthosechangesweresignificant,andasaresultdrawgeneralconclusionsaboutwhetherornotclientsareexperiencingpositiveandsignificantchanges.SeeAttachmentTableA2forasummaryofinstrumentsand

howtheyarescaledandscored.


RespiratoryControl

Two‐thirds(65%)ofclientswhoadministeredanACT/CAT–beforeandafterCHWinterventions–reportedanimprovementinrespiratorycontrol,with47%reportingasignificantimprovement.Oneinfive(19%)asthmaclientsreportedadecreaseinrespiratorycontrolatfollow‐up.ThirtypercentofCOPDclients

reportedadeclineincontrol.Pooreroutcomesmaybepartlyassociatedwiththetimingoffollow‐upvisitswhichwereclusteredinthespringduringpeakallergyseason.

AtthetimeofthefirstCHWhomevisit,42%ofasthmapatientsreportedtheirasthmawascontrolled(ACT>19)–thisincreasedto67%atfollow‐up.Onaverage,ACTscoresincreasedbyalittleunderthreepoints.Thisincrease,whichindicatesimprovement,wassignificant(α=.002<.05)forallasthmaclients.

Table7.AsthmaandCOPDControlTestResults

AllPersons PersonswithAsthma PersonswithCOPDN= 45 32 13

Significantlybetter 47% 50% 38%Better 18% 16% 23%Nochange(‐1,0,+1) 13% 16% 8%Worse 16% 16% 15%Significantlyworse 7% 3% 15%

CATscoresforCOPDpatientsdecreased(thedirectionofimprovement)althoughtheimprovementwasnotsignificant(α=.151>.05).ThepercentageofCOPDclientswhoreportedtheirCOPDwas“controlled”or

hadlowimpact(CATScore<10)increasedfromzeroto21%).

Table8.MeanChangeinAsthmaControlTestandCOPDAssessmentTest

MeanPre–MeanPost MeanImprovement(95%CI) Pr(T>t)Meandiff>0Asthma* 18.321.2 2.9(1.04.9) .0021COPD 25.122.8 2.3(‐2.47.0) .1511*Excludestwoclientsunderage4whoreceivedtheTRACK,oneshowedsignificantimprovementandoneshowedminorimprovement

Apreliminaryanalysisofrespiratorycontroloutcomesbyintensityofweatherizationandhomevisitinterventions,medicalacuityofpatients,orbuildingneeddidnotyieldevidenceofsignificantdetectable

differences.Thiswasnotsurprisinggiventhesmallsamplesizes,highdegreeofvariabilityininterventionsandclientconditions,andlackofaclearrelationshipbetweenacuity(need)andinterventionlevel.

OverallQualityofLife

Clientsratedhowmuchtheirrespiratoryconditionimpactedtheirsymptoms,dailyactivitiesandmentalhealth(specificitemsarelistedinattachedtables):

• Adultswithasthmaratedimpactsin15areasonascaleofone(majorimpact)toseven(noimpact)

• Parentsofchildrenwithasthmaratedimpactsin13areasonascaleofonetoseven• AdultswithCOPDrated12areasonascalezero(noimpact)tosix(majorimpact)


AswithcontrolmeasuresforCOPDclients,alowscoreindicatesbetterQualityofLife(closertooneisbetter);forasthmaclients,ahigherscoreisbetter.Scoresforallitemsareaveragedforanoverall

assessmentofQualityofLife.Achangeinaverageofscoreofonepointisconsideredsignificant.

SevenintenclientsreportedanimprovementinaveragescoresforQualityofLifeindicators,with38%reportingasignificantimprovement.Half(47%)ofasthmaclientsandnoCOPDclientsreportedsignificantimprovement.

Table9.AsthmaandCOPDQualityofLifeResults

Significantimprovement(>1.0)

AllPersons PersonswithAsthma PersonswithCOPD

N= 37 30 7Significantlybetter 38% 47% 0%Better 32% 33% 29%NoChange(‐.1,0,+.1) 14% 13% 14%Worse 11% 7% 29%Significantlyworse 5% 0% 29%

ThemeanQualityofLifescoreforadultswithasthmaandforthecaregiversofchildrenwithasthmashowed

astatisticallysignificantincreasebyoveronepoint.AllQualityofLifeareasshowedsomeimprovement.Theareasofgreatestimprovement(seeAttachmentTablesA3andA4)were:

• Symptoms(coughingandchesttightness)• Sleep(bettersleepforclientsandcaregivers)

• Anxiety,frustrationandworry• Fewerimpactsandinterruptionsforcaregivers

Table10.ChangeinMeanQualityofLifeIndexforAsthmaandCOPDClients

MeanPre–MeanPost MeanImprovement(95%CI) Pr(T>t)Meandiff>0

AsthmaAdult* 4.205.51 1.31(.641.99) .0006AsthmaChild(caregiver) 5.576.85 1.12(.461.76) .0011COPD 3.713.45 ‐.1(‐1.5.96) .5878

Table11suggeststhatmuchofthemovementwasfrom“ModeratetoMinorimpact”to“Noimpact”.

Table11.AsthmaImpactonQualityofLifeBeforeandAfterIntervention

ImpactonQualityofLife BeforeIntervention AfterInterventionAsthma(n=) (30) (30)Severe(3.9orlower) 23% 3%Moderate(4–5.9) 40% 27%Minor(6‐6.9) 33% 20%None(7.0) 3% 50%


OverallMeanQualityofLifescoreforCOPDclientsshowedslight,statisticallyinsignificantdecrease(Table11).Resultsforspecificmeasuresweremixedwithsomeareasshowingimprovement:

• Shortnessofbreathatrest

• Anxietyaboutbreathing• Impactsonsocialactivities• Chestmucus

Andothersreportedasbeingworse(seeAttachmentTableA5):

• Coughing

• Shortnessofbreathwhiledoingphysicalactivity

CHWsnotedthatpoorerreportedqualityoutcomeswererelatedtogreatermedicalacuityandfragilityforadults,especiallythosewithCOPD.Theyalsonotedthatinsomecaseseducationincreasedparticipantawarenessofhowtheirhealthconditionswereimpactingtheirlives.

ImpactsonActivitiesandSelf‐reportedMedicalUtilization

Forty‐twoclientsreportedhowtheirrespiratoryconditionaffectedschool,workandmedicalvisitsviatheACQandACQC.

• WorkorSchool:Duringthepastfourweeks,howmanydaysofwork/school/normalactivitiesdidyoumissduetoyourasthmaorCOPD?

• CaregiverImpacts:Duringthepast4weeks,howmanydaysofwork/school/normalactivitiesdidanyonewhocaresforyoumissduetoyourasthmaorCOPD?

• UrgentCare:Inthelastyear,howmanytimeshaveyouvisitedUrgentCareorhadasamedayvisitwithaproviderduetoasthmaorCOPD?

• EmergencyRoomVisits:Inthelastyear,howmanytimeshaveyouvisitedtheEmergencyRoomduetoasthmaorCOPD?

• HospitalAdmissions:Howmanyoftheseresultedinahospitaladmission?

Wecalculatedthetotalnetchange(pre–post).Atthetimeofthepre‐questionnaire,clientsreportedvisitsintheprioryear.Forthefollow‐up,clientswereaskedtorecallthenumberofvisitssincetheprevioushomevisit,typically9to12months.

AsshowninTable13,therewasanetdecreaseinmissedworkorschoolandmedicalvisitsacrossallclients.

AsthmaclientsreportednetreductionswithgreaterreductionsinUrgentCareandEmergencyRoomvisits.COPDclientsreportednetincreases–especiallyincaregiverimpactsandUrgentCarevisits–bothofwhicharelikelylinkedtoCOPDclients’greaterinitialmedicalacuity.


Table12.TotalNetChange(FewerisBetter)inMissedDaysandMedicalVisits(n=42)

Workorschool(4weeks)

Caregiver(4weeks)

UrgentCare(Year)

EmergencyRoom(Year)

HospitalAdmission(Year)

TotalNetChange ‐4 ‐2 ‐4 ‐15 ‐6TotalAsthma ‐7 ‐8 ‐12 ‐15 ‐8Under4 ‐3 ‐2 ‐4 ‐4 04‐11 ‐1 ‐1 2 ‐2 012‐17 ‐3 ‐4 ‐5 ‐3 ‐4Adults 0 ‐1 ‐5 ‐6 ‐4TotalCOPD 3 6 8 0 2

Table13reportsnetchangesperclientpermonthorperyearwhichwouldbeofuseinprojectingpotentialprogramimpactstofutureprograms.

Table13.NetChangeperClient

Workorschool(4weeks)

Caregiver(4weeks)

UrgentCare(Year)

EmergencyRoom(Year)

HospitalAdmission(Year)

Total ‐0.10 ‐0.05 ‐0.10 ‐0.36 ‐0.14TotalAsthma ‐0.23 ‐0.27 ‐0.40 ‐0.50 ‐0.27COPD 0.25 0.50 0.67 0.00 0.17

Summary

InitialresultsfromthePCHHInitiativearepromising.Theysuggestthatdespiteacomplexclientmixandsmallsamplesize,itwaspossibletodetectevidenceofimprovedhealthoutcomes,improvedQualityofLifeandloweruseofmedicalservices.Thiscasestudyalsohighlightsthechallengesandopportunitiesof

providingintegratedweatherization,healthyhomesandhomevisitservicestolowincomeweatherizationclients.

• Lowincomeweatherizationclientsarediversewithmultiplehealthconditions,livingsituationsandhealthcarepayers.

• AdultswithasthmaandCOPDhavehighmedicalacuityandarelikelytobemedicallyfragile.Athirdofthosereceivingservicesmovedout,droppedout,diedorhadotherserioushealthreversals.Whileremainingandfutureoccupantsarelikelytoexperiencebenefits–thiscomplicateseffortsto

directlymeasureandattributehealthoutcomesanddecreasedmedicalsystemutilizationtoprogramservices.

• CHWsmusthavetheskillstoaddressmultiplehealthconditionsincludingasthma,COPD,mental

healthandco‐morbidconditions.Weatherizationprogramstaffalsoneedsadditionaltrainingandsupporttoworkwiththeseclients.

• Itischallengingtoalignweatherizationprogramrequirements,clientneedandclientreadiness.


• ItisessentialtocoordinateweatherizationandCHWservicesandmaintaincoordinationofservicesoveralongperiodtoseebenefits.Asthestorieswhichclosethiscasestudyindicate,progressin

individualcasescanbeincremental,maytakemultiplevisitsandinvolvesetbacks.

WeclosewithfourstoriesprovidedbyHealthDepartmentCHWsthatillustratehowclientsdescribetheprogramandthedifferenceitmadeintheirlives.And,why–despitethechallengesdescribedabove–weatherizationstaffatPCHSandCHWsattheHealthDepartmentremainpassionateaboutthework.

Pseudonymsareusedtoprotectclientconfidentiality.Additionalstoriesareattached.

StoriesfromtheField

Loraine

Lorraineisasingleretiredveteran,whohasseveralhealthissues.Shehasdealtwithasthmaformany

years.Duringherfollow‐upinterview,shesharedhowhappyandgratefulshewasfortheWx+Hprogram.Herasthmaisimprovedandshehasbeenabletobeoutinheryardgardeningmore.“TheonlytimeItakeabreakiswhenIoverdoitduetoarthritis.”SinceLorrainestartedtheprogramshe

usesaspacer(aplasticormetaltubethatmakesiteasiertouseaninhaler)withhermedication,hasnothadanyurgentorsamedayPrimaryCareappoints–duetoasthma–andherACTscorewentfrom10to25,indicatingwell‐controlledasthma.SheisbetterabletovacuumwiththelightweightHEPA

vacuumprovidedbytheprogram.Sheisenjoyingthatshehasproperinsulationthatkeepsherhomewarmerinthecolderweatherandworkingfansthatareextremelyhelpful,aswell.ShesharedwiththeAsthmaCHWthatshewas“…gratefulforthecontractorsthatservicedmyfurnaceandrepairedit.I

couldnothaveaffordedthat.”

TheDiAngelos

Mr.andMrs.DiAngelohadnoideaprogramslikeWx+Hexisteduntiltheylearnedaboutitatthefoodbankwheretheyvolunteered.Theywereworriedabouttheirfinances,butdidnotwanttoletothersknowwhatwasgoingon.TheyhadaveryhighelectricbillandMrs.DiAngelohadtorefillherasthma

inhalers.Theyhadtochoosewhethertopaytheirelectricbillorrefillthemedication.

Oneoftheladiesthatvolunteeredwiththemnoticedthattheywerenotactingnormalandaskedifeverythingwasokay.Mr.DiAngeloletherknowthathewasworriedabouthiswifenotgettinghermedication.Hisfellowvolunteerpattedhimonhisbackandsaid,“Don’tworry.Ihaveanumberyoucan

callandtheywillhelppayforyourelectricbill.”HecalledEnergyAssistancethatdayanda“…reallyniceladyansweredthephoneandtalkedtomeaboutEnergyAssistanceandtheWeatherizationPlusHealthprogram.”Shetoldhimwhatinformationtobringintotheoffice,inordertoapplyandqualify

fortheEnergyAssistanceprogramandalsoforWx+Hprogram.Afterhisappointment,hetoldMrs.DiAngelothatsomeonefromtheHealthDepartmentwasgoingtocomeandteachheraboutherasthma,andthatweatherizationstaffwouldalsocomeandwalkthroughthehousetoseewhatrepairs

theirhomeneeded.

Mr.DiAngelosaid,“Whenthetimecameforourasthmaappointment,wefeltsorelieved.TheCommunityHealthWorkershowedbothofusthatmywife,forsomanyyears,wasnotusingher


inhalerstheproperway.Wealsofoundoutthatthecleaningsupplieswewereusingwerecausingmywife’sasthmatonotgetbetteratall.Orinotherwords,Iwouldsaywebothwerebreathingthisvery

strongchemicalthatsmelledgoodbutwasnotsafeforustouse.”TheCHWprovidedthefamilywithagreencleaningkitandaHEPAvacuum.

Weatherizationstaffdeterminedthatthehomeneededinsulationunderthefloors,bathroomexhaustfans,andaductlessheatpumpinthelivingroomandairfilter.

“Wehavenoticedabigchangeinsideourhomesincetheworkwasdone.Wehavebeendoingwhatthe

(CommunityHealth)Workerrecommendedandwe’venoticedourelectricalbillisnothighanymore.”Mrs.DiAngelo’sasthmahasimprovedsinceherlasthomevisitandshecandomorethingsaroundthehomeandgooutforlongerwalks.“Thankyoutoeveryonethatmadethispossible,wefeelsoblessed,”

shesaid.

Linda

Lindaexpressedgratitudeforthesetypesofprograms,especiallyfor“Seniorslikemyself,thatarejustlivingoutofanSSIpaycheck…thatsometimeshavetopickiftheyeatorpaytohavearoofoverthem.”Aftertheweatherizationwork,herwinterbillsdroppedfrom$300dollarsamonthto$98‐$150

dollars.”Lindaisverygratefulwiththeasthmaeducationshereceivedthat“explainseverything”andsheisfollowingtherecommendationsofherCHW.HerACTscorehasimproved.OnhersecondhomevisittheCHWnoticedLindahadstoppedusingtheplug‐inairfreshenerssinceherfirsthomevisit.Linda

feelsherasthmahasimprovedandsheisabletodomorearoundherhomeandcangardenmorewithoutrunningoutofbreathlikebefore.Shenolongerneedstouseherinhalermorethen2‐3timesperweek.Shehadgreatcomplimentsaboutstafffromtheweatherizationprogram.“Alltheworkthey

didinmyhomewassuchablessingtome.Icouldneverhavedoneitonmyown,”shesaid.

Rose

RoseenteredtheWx+Hprogramasasinglemother,tofindhelpforhertwochildrenwhobothsufferedfromasthmasincetheywereyoung.Shedidnotunderstandthecorrectuseoftheirprescribedasthma

medicationand,asaresult,wasgivingthechildrenAlbuterolwhensheshouldhavegiventhemQvar,andgivingthemQvarwhensheshouldhavegiventhemAlbuterol.

Thehomehadmoderateclutterthroughout,andmoldinherbathroom–duetoawaterleakunderhertrailer.AfterreceivingrecommendationsandsuppliesfromtheCHW,shenowunderstandsher

children’smedication.Sheisusinghergreencleaningsupplies–especiallytostayontopofthemold–andhasreducedtheclutter.Shecouldnotbelieveeverythingshewasabletodowithvinegar.Shetalkedaboutopeningherwindowsmoreoftenforventilationandhowmuchthevacuumhashelped.

Herplumbingwasfixedbyprogramcontractors–somethingshesaidshecouldnotaffordtofix.

Thechildren’sasthmaismuchbetter,Rosesaid,“Ionlyseeadifferencewithweatherandseasonchanges,butit’snotasbadasbefore.”Sheappreciatesthesuppliesandtheinformationandisthankfulfortheprogramandwhatithasdoneforherfamily.


Attachments

MeasureProfileforPCHHWx+HProjectsComparedtoAllOtherWx+HPilotGrantees

TableA1.PercentageofWx+HProjectswithHealthyHomesandWeatherizationMeasureInstalled(n=43)

PlusHealthMeasures WeatherizationMeasures AllGrantees PCHS AllGrantees PCHSGreencleaningkit 94% 88% Airsealing 77% 77%Bedding(dustmite) 71% 62% Floorinsulation 44% 56%Mechanicalventilation 65% 65% Atticinsulation 54% 60%HEPAvacuum 65% 79% Wallinsulation 12% 2%Walk‐offmats 65% 87% Windows 17% 7%COdetector 57% 54% Door 19% 16%LowVOCflooring 33% 6% Ductinsulation 20% 23%Smokedetector 24% 4% Ductrepair 10% 26%Advancedventilation 18% 8% Ductsealing 33% 44%HEPA/MEPAfilter 17% 17% HVAC‐replace 33% 60%HVACcleaning 17% 4% FurnaceTandCn 22% 47%Airfilter 15% 33% HVAC‐repair 13% 16%Plumbingrepair 13% 21% Thermostat 15% 26%Gutter,downspout 13% 10% Passiveventing 44% 47%Moisture/moldabatement 13% 6% Lighting 33% 47%Roofrepair/replace 11% 21% WHlowcost 52% 65%Pestmitigation 9% Waterheater 12% 12%Comprehensivecleaning 8% Electricalrepair 13% 19%Crawlspace 7% Wxrepair 1% Slip/fallprevention 5% 10% Dehumidifier 2% 2% Darkercellcolorsindicatehigherratesofinstallation.Blankcellsindicatethatameasurewasnotinstalledbythegrantee.


SummaryofClientQuestionnairesUsedInCaseStudy

ThefollowinginstrumentswereadministeredbyCHWsduringfollow‐upvisits.

TableA2.ClientQuestionnaireSummary

InstrumentName ScoreRange InterpretationNotesAsthma WorseBetter

RespiratoryControl

AsthmaControlTest(ACT)Track(underage4)

025

0100

20orgreaterincontrol +/‐3significantchange

80orgreaterincontrol +/‐10significantchange

ActivitiesLostSchoolMedicalcare

AsthmaControlQuestion(ACQ)Separateinstrumentsbyagegroup

4+0

4ormorecountedas4.NetPost–Preeventssummed‐decline(negativechangeorreductionsdesirable)

QualityofLife PACQLQ(Children)13ItemsAQLQ(Adults)15items

17 Averagescore1‐4SevereImpact,4‐5.9Moderate,6‐6.9minor,7noimpact.

Anincreaseordecreaseinaveragescoreacrossallitemsgreaterorequaltooneisasignificantchange

COPD Control COPDAssessmentTest(CAT) 400 Lowerisbetter<10LowImpact,10‐20

ModerateImpact,21‐30HighImpact,Over30VeryHighImpact

+/‐5significantchangeActivitiesLostSchoolMedicalcare

AsthmaControlQuestionsforCOPD(ACQC)

4+1 4ormorecountedas4.NetPost–Preeventssummed‐decline(negativechangeorreductiondesirable)

QualityofLife ClinicalCOPDQuestionnaire(CCQ)–12items

60 Lowerisbetter,5.5orhigherverypoor,4‐5.4poor,2‐4moderate,under2good.

Anincreaseordecreaseinaveragescoreacrossallitemsgreaterorequaltooneisasignificantchange


QualityofLife

TableA3.QualityofLifeOutcomesforAdultswithAsthma–SummaryofMeanChangeinScore

AsthmaQualityofLifeQuestionnaire(AQLQ)Score(1=allthetime–7noneofthetime) Mean

AdultQualityofLifeQuestionnaireitems–Duringthepastweek,howconcernedwereyouaboutthesethings?

PreScore

Improve‐ment

Feelbotheredbycoughing? 3.2 1.0

Havedifficultygettingagoodnight'ssleepasaresultofyourasthma? 3.8 1.0

Feelbotheredbyorhavetoavoidcigarettesmokeintheenvironment? 2.9 0.9

Experienceafeelingofchesttightnessorchestheaviness? 4.1 0.8

Feelconcernedabouthavingasthma? 4.2 0.7

Feelfrustratedasaresultofyourasthma? 4.4 0.7

Feelbotheredbyorhavetoavoiddustintheenvironment? 3.2 0.6

Socialactivities(suchastalking,playingwithpets/children,visitingfriends/relatives) 4.8 0.6

Feelshortofbreathasaresultofyourasthma? 3.8 0.5

Experienceawheezeinyourchest? 3.8 0.5

Strenuousactivities(suchashurrying,exercising,runningupstairs,sports) 4.0 0.4

Work‐relatedactivities(tasksyouhavetodoatwork,schooloranytasksyouhavetodomostdays) 5.3 0.4

Feelafraidofnothavingyourasthmamedicationavailable? 5.3 0.2

Moderateactivities(suchaswalking,housework,gardening,shopping,climbingstairs) 4.5 0.2

Feelbotheredbyorhavetoavoidgoingoutsidebecauseofweatherorairpollution? 4.5 0.2

TableA4.QualityofLifeOutcomesforCaregiversofChildrenwithAsthma–SummaryofMeanScoreChanges

ParentsofAsthmaticChildrenQualityofLifeQuestionnaire(PACQLQ)Score(1=allthetime–7noneofthetime) MeanParentAsthmaQualityofLifeQuestionnaireitems–Duringthepastweekhowconcernedwereyouaboutthesethings?

PreScore

Improve‐ment

Yourchild'sperformanceofnormaldailyactivities? 5.0 1.8Didyourfamilyneedtochangeplansbecauseofyourchild'sasthma?

5.3

1.7

Didyourchild'sasthmainterferewithyourjoborworkaroundthehouse? 5.3 1.6

Didyoufeelhelplessorfrightenedwhenyourchildexperiencedcough,wheezeorbreathlessness? 5.3 1.6

Wereyouawakenedduringthenightbecauseofyourchild'sasthma? 5.4 1.2

Aboutbeingover‐protectiveofyourchild? 5.8 1.1

Didyoufeelfrustratedorimpatientbecauseyourchildwasirritableduetoasthma? 5.8 1.0

Didyouhavesleeplessnightsbecauseofyourchild'sasthma? 5.5 1.0

Aboutyourchildbeingabletoleadanormallife? 5.8 1.0

Didyoufeelupsetbecauseofyourchild'scough,wheezeorbreathlessness? 5.9 0.9

Didyoufeelangrythatyourchildhasasthma? 6.2 0.8

Aboutyourchild'sasthmamedicationsandsideeffects? 6.3 0.6

Wereyoubotheredbecauseyourchild'sasthmainterferedwithfamilyrelationships? 6.3 0.6


TableA5.QualityofLifeOutcomesforAdultswithCOPD–SummaryofMeanScoreChanges

ClinicalCOPDQuestionnaire(CCQ)–Duringthepastweek,howconcernedwereyouaboutthesethings?(Zerononeofthetime6allofthetime) PreScore Change

Shortofbreathwhileatrest? 3.6 2.0

Howoftendoyoufeelanxiousbecauseofyourbreathingproblems? 2.6 1.1

Socialactivities(suchastalking,beingwithchildren,visitingfriends/relatives)? 3.5 0.9

Didyouproducesputumorphlegm(chestmucus)? 3.9 0.8Howoftendoyoufeeldepressedbecausebreathingproblemskeepyoufromdoingwhatyouenjoy? 2.4 0.7

Dailyactivitiesathome(suchasdressing,washingyourself)? 2.9 0.3

Moderatephysicalactivities(suchaswalking,housework,carryingthings)? 3.9 0.1Strenuousphysicalactivities(suchasclimbingstairs,hurrying,participatinginsports)? 3.9 0.0

Concernedaboutgettingacoldoryourbreathinggettingworse? 4.0 ‐0.3

Depressed(down)becauseofyourbreathingproblems? 3.5 ‐0.3

Didyoucough? 4.0 ‐0.4

Shortofbreathwhiledoingphysicalactivities? 4.0 ‐0.5

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