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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
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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
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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
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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.
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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).
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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.
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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.
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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.
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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)
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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%
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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.
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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.
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• 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
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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.
Page16PierceCountyHealthyHomesCaseStudy
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.
Page17PierceCountyHealthyHomesCaseStudy
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
Page18PierceCountyHealthyHomesCaseStudy
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
Page19PierceCountyHealthyHomesCaseStudy
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