# Establishing an Asthma Follow-Up Protocol on a Native American Reservation 

# 2007 - 2008 

# 

# Environmental Public Health Leadership Institute Fellow:

#  LCDR Gary W. Carter, MPH

*Institutional Environmental Health Officer;* Billings Area Indian
Health Service

*2900 4^th^ Avenue North*

*Billings, Montana 59107*

*(406) 247-7090*

*gary.carter@ihs.gov*

# Mentor:

### **Charles Treser; MPH**

*Senior Lecturer;* University of Washington

# (Acknowledgements):

### **Allyson Kelley, MPH**

*Project Director;* Rocky Mountain College

### **CDR Ken Hull, RS**

*Tribal Environmental Health Officer;* Ft. Peck Tribal Health Department

### **George Allen, PE**

*Associate Area Director;* Billings Area Indian Health Service

### **JoEllen Maurer, RPh**

*Chief Pharmacist;* Verne E. Gibbs IHS Health Center

> ![](media/image1.jpeg){width="1.3756944444444446in"
> height="0.6368055555555555in"}

# EXECUTIVE SUMMARY:

A Native American reservation in Montana is experiencing an asthma
age-adjusted prevalence significantly higher than the national average.
Native American healthcare on this reservation is delivered by an Indian
Health Service (IHS) ambulatory healthcare clinic and a community health
center. The IHS has experienced reduced funding levels for each of the
past several years and current healthcare funding for Native Americans
is estimated to be approximately 60% of need.^1^

Patients who come to the IHS clinic for treatment of asthma or report to
the emergency room (ER) at the community health center are not scheduled
for follow-up appointments or provided environmental health services
such as having their home assessed for potential asthma triggers. The
typical asthma patients are treated and released at either the clinic or
the community ER and return to their home or school environments where
they are re-exposed to asthma triggers.

Using systems thinking methodology a two-tiered intervention was
developed: the establishment of a standard follow-up protocol used by
healthcare providers to effectively manage asthma cases, and; the
development of a home visit program where asthma triggers can be
identified in the home and education provided. These two programs would
be linked through a communication mechanism between the clinicians and
the environmental health services department.

An asthma task force was assembled to develop, market, and implement
interventions. Partnerships were formed between several entities in
order to accomplish the goals. The task force meets via teleconference
every month and follows an established action plan.

Native Americans experience high asthma prevalence and low access to
healthcare services. A focus on primary prevention rather than on
secondary and tertiary care should reduce asthma levels in this
population. Successful prevention requires a shift of resources away
from clinical services and toward ancillary services that demonstrate
long-term, more efficacious results.

# INTRODUCTION/BACKGROUND:

####### The Native American reservation under consideration may be described as "typical" in that poverty is high and living conditions are poor. Also, it is well known that Native Americans experience numerous health disparities, many of which may be related to poverty. 

####### The age-adjusted prevalence of asthma on a Native American reservation in Montana was found to be almost twice the prevalence of all races within the United States (Figure 1.) While there are many other health disparities such as high prevalence of diabetes and injury rates, asthma triggers can be controlled and clinical protocols can be established in order to reduce the number and severity of asthma attacks.

####### 

####### \*Native American/Alaska Native in United States

####### Sources: National Health Interview Survey; National Center for Health Statistics; Office of Environmental Health and Engineering, Billings Area Office of the Indian Health Service

####### 

####### ***Problem Statement:***

####### Patients who report to the IHS clinic or the community health center ER for treatment of asthma are not scheduled for follow-up appointments or provided environmental health services such as having their home assessed for potential asthma triggers. The typical asthma patients are treated and released at the clinic and return to their home or school environments where they are re-exposed to asthma triggers.

####### ***Behavior Over Time Graph:***

####### When there is an asthma-related visit to the ER or IHS clinic, the patient is treated with quick-acting medication and released. There is little focus on asthma management protocols and home visits to identify and potentially remove asthma triggers; therefore, the cycle of treatment and release continues to rise.

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#######  ***Causal Loop Diagrams and applicable archetypes:***

####### The system operating within this public health issue is a "Shifting the Burden"^2^ archetype with a balancing loop being created by the treatment of symptoms; namely, the ability to visit the emergency room (ER) and the use of quick acting inhalants to allow the patient to breathe easier. However, two long-term balancing loops exist that address the core issues: 1) a clinical protocol for asthma management and; 2) elimination of asthma triggers in the home and elsewhere. Therefore, this author proposed two separate "Shifting the Burden" archetypes, each identical to the other except for the long-term solution. It should also be noted that for the second long-term solution, environmental health services, to engage, the first long-term solution, clinical protocol for asthma management, must be in place. This temporal relationship exists because a clinical protocol system would capture the asthma case, which would then be referred to the environmental health services (EHS) department, who could then respond by performing a home assessment to identify and potentially eliminate the triggers. 

#######  ***Shifting the Burden -- Step 1: Clinical Protocol for Asthma Management***

***Shifting the Burden -- Step 2: Environmental Health Services***

####### ***10 Essential Environmental Health Services^3^:***

This project addresses several of the ten essential environmental health
services and the three functions of the Institute of Medicine Report^4^:

-   **Assessment**

    -   Monitor health -- This was performed by analyzing data to
        discover a high prevalence of asthma

    -   Diagnose and Investigate -- Using the Systems Thinking model,
        recurring cycles leading to lack of follow-up were discovered
        and how certain elements contributed, such as poor communication
        between the community clinic and the IHS clinic.

-   **Policy Development**

    -   Inform, Educate, Empower -- Asthma information kits were
        distributed to schools and individuals in the community.

    -   Mobilize Community Partnerships -- Allyson Kelley, the project
        director for the EPA Indian Country CARE grant was central to
        these efforts. Through the CARE grant, she coordinated a
        community-based workshop designed to develop intervention ideas
        for asthma.

    -   Develop Policies -- The IHS health center is currently working
        to develop an asthma management policy.

-   **Assurance**

    -   Link to/Provide Care -- A communication bridge is being
        established between the emergency department at the community
        hospital and the IHS health center.

    -   Assure Competent Workforce -- In-service education will be
        provided to the clinicians regarding asthma management and the
        new protocol policy.

    -   Evaluate -- The asthma prevalence will be re-examined each year
        to evaluate the effectiveness of the interventions.

![](media/image2.png){width="2.94375in" height="3.0in"}

Figure 2: Reprinted from CDC's "National Strategy to Revitalize
Environmental Public Health Services"

####### 

####### ***National Goals Supported*** 

1\. This project seeks to support the following Healthy People 2010
Objectives^5^ and the CDC Health Protection Goals^6^:

-   [Healthy People 2010]{.underline} Access to Quality Health Services:
    1-7: Core competencies in health provider training.

    -   Through the implementation of a standardized asthma management
        protocol the health providers will be required to understand how
        to manage and track asthma cases through the use of spirometry
        and know pertinent information that must be communicated to the
        patient.

-   [CDC Health Protection Goals]{.underline} #44: Promote homes that
    are healthy, safe, and accessible.

    -   By enhancing communication between clinicians and the
        Environmental Health Services department a system can be
        developed where patient's homes are surveyed by trained
        individuals who can identify asthma triggers and assist the
        homeowner in removing those triggers.

-   [CDC Health Protection Goals]{.underline} #45: Promote adoption of
    behaviors that keep people healthy and safe in their homes.

    -   Environmental tobacco smoke has been shown to have a significant
        association with increased prevalence of asthma and respiratory
        symptoms in school children.^7^ This project seeks to inform
        parents of the relationship between cigarette smoking inside the
        home and asthma attacks suffered by their children and others
        living with asthma.

-   [CDC Health Protection Goals]{.underline} #53: Promote compliance
    with evidence-based guidelines for preventing, identifying, and
    managing disease in healthcare settings.

    -   One proposed asthma management protocol is entitled "*Global
        Strategy for Asthma Management and Prevention."*^8^ This is a
        known effective strategy that has been shown to be preferred by
        95% of military clinicians.^9^

-   [CDC Health Protection Goals]{.underline} #56: Promote
    patient-centered clinical care and prevention services in healthcare
    settings.

    -   The written asthma management plan (WAMP) focuses on the
        individual patient's health status and manages the case based on
        that individual's progress. Further, by linking the clinician to
        the environmental health professional, this project seeks to
        address a health condition through primary prevention.

2\. This project supports the following goals of the National Strategy
to Revitalize Environmental Public Health Services:^10^

-   [Activity I-B-3:]{.underline} *"Promote institutional and strategic
    changes to foster ongoing coordinated efforts with strategic
    partners and other stakeholders to implement and evaluate
    environmental interventions to improve health and well-being for
    urban and rural residents."* This activity was accomplished by
    looking directly at health outcomes to determine the severity of an
    environmental health issue and persuading the local healthcare
    institutions to communicate among themselves and adopt standardized
    protocols to address the health issue. As a part of that protocol,
    the healthcare providers were asked to communicate with the local
    environmental health professionals in order to assess homes for
    asthma triggers.

-   [Activity VI-AI-1:]{.underline} *"Identify stakeholders who
    influence all components of the environment (built and natural) that
    have an impact on environmental public health services."* This
    activity was met by providing information to schools, Head Start
    facilities, and home dwellers on what asthma triggers are and how to
    remediate them.

-   [Activity VI-AI-2:]{.underline} *"Support activities (e.g.,
    conferences, meetings, seminars, etc.) that influence stakeholders
    to work together to improve environmental public health."* This
    activity was met by the Indian Country CARE director who set up and
    coordinated the Community Leadership Training workshop that brought
    community leaders together to discuss asthma and, through a directed
    approach, brain storm asthma intervention activities.

-   [Activity VI-AI-3:]{.underline} *"Develop mechanisms for regular
    communication and coordination among stakeholders"* This activity
    was met by directing the healthcare providers at the community
    health clinic and the IHS health clinic to communicate between
    themselves when confronted with an illness of environmental
    etiology. Also, communication channels were fostered between the IHS
    health clinic and the Tribal Environmental Health Services (EHS)
    department.

3\. This project supported the goals of the Environmental Health
Competency Project: Recommendation for Core Competencies for Local
Environmental Health Practitioners^11^ in the following ways:

-   Goal A2: *Data Analysis and Interpretation: The capacity to analyze
    data, recognize meaningful test results, interpret results, and
    present the results in a meaningful way to different types of
    audiences*

    -   Excel spreadsheets were used to create a meaningful graphic to
        convey the state of asthma on the reservation

    -   Studies and reports on asthma were read on conveyed to the
        audiences in an understandable manner

-   Goal B7: *Partnering: The capacity to form partnerships and
    alliances with other individuals and organizations in order to
    enhance performance on the job*

    -   Networks of professionals within IHS such as the Chief
        Pharmacist, clinicians, and public health nurses were formed.

    -   Networks were formed between community organizations such as EPA
        Indian Country CARE, Tribal Environmental Health Services, and
        local schools

    -   The cultivation of effective linkages and partnerships is being
        accomplished through monthly teleconferences and regular contact
        and presentations to key parties.

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-   Goal C1 *Education: The capacity to use the environmental health
    practitioner\'s front-line role to effectively educate the public on
    environmental health issues*

    -   Accurate information on asthma and the desired actions are
        effectively communicated in a culturally sensitive manner

    -   Primary prevention is strongly emphasized to the clinicians and
        the homeowners. Homeowners, for example, are provided with an
        explanation of how to reduce asthma triggers in the home by
        eliminating second-hand cigarette smoke or minimizing pets in
        the home

***Project Logic Model:* Goal:** To reduce the rate of death and illness
due to injuries and environmental related diseases

# 

+------------+--------------+--------------+-------------+------------+
| **Resource | ##           | ### Outputs  | **Short &   | *          |
| s/Inputs** | # Activities |              | Long Term   | *Impacts** |
|            |              | **TIER I**   | Outcomes**  |            |
+------------+--------------+--------------+-------------+------------+
| ##         | **Program    | -   Policy   | #           | **         |
| ## Funding | Design and   |     develo   | ## Learning | Behavior** |
|            | D            | pment/review |             |            |
| #          | evelopment** |              | -           | -          |
| ### IHS Se |              |    committee |   Increased |    Process |
| rvice Unit | -   Form     |     created  |     co      |            |
|            |              |     at       | llaboration |  developed |
| -   IHS    |    committee |     hospital |     between |     to     |
|     Area   |              |              |             |     a      |
|     Office | -   Develop  | -   Policy   |    partners | nticipate, |
|            |              |     and      |             |            |
| -   Tribal |    follow-up |              | -           |  identify, |
|     Health |     policy   |    procedure |   Clinician |     and    |
|            |     and      |              |             |            |
| Department |              |    developed |   awareness |  follow-up |
|            |   procedures |     and      |     of      |     on     |
| -   EPA    |              |              |     asthma  |     env    |
|     CARE   | -            |  implemented |             | ironmental |
|     Grant  |    Interview |              |   follow-up | ly-related |
|            |     CM       | -            |             |     upper  |
|            | O/Clinicians | Presentation |   protocols |     r      |
|            |              |              |             | espiratory |
|            | -   Identify |    developed | -           |     disea  |
|            |     who      |     and      |   Executive | ses/asthma |
|            |     could    |              |             |            |
|            |              |    presented |    leaders' | -          |
|            |  participate |     to       |             |  Community |
|            |     in site  |     partners |   awareness |            |
|            |     surveys  |              |     of      |   members/ |
|            |              | -   Tribal   |     asthma  | asthmatics |
|            | -   Meet     |     health   |             |            |
|            |     with     |     and      |   follow-up |   identify |
|            |     tribal   |              |             |     and    |
|            |     health   |    executive |   protocols |     avoid  |
|            |              |     leaders  |             |     env    |
|            |    officials |     indicate |             | ironmental |
|            |     and      |     buy-in   |             |            |
|            |     Mon      |              |             |  stressors |
|            | tana/Wyoming | -   Id       |             |     at     |
|            |     Tribal   | entification |             |     home   |
|            |     Leaders  |     of who   |             |     and in |
|            |     Council  |     performs |             |     their  |
|            |              |     site     |             |            |
|            |    officials |     surveys  |             |  community |
|            |              |              |             |            |
|            | -            | -            |             |            |
|            |    Establish | Standardized |             |            |
|            |     c        |     clinical |             |            |
|            | ommunication |              |             |            |
|            |     link     |    follow-up |             |            |
|            |     between  |     protocol |             |            |
|            |              |              |             |            |
|            |    community |    developed |             |            |
|            |     health   |     and      |             |            |
|            |     clinic   |              |             |            |
|            |     and IHS  |   instituted |             |            |
|            |     health   |              |             |            |
|            |     clinic   | -   \# of    |             |            |
|            |              |     patients |             |            |
|            |              |              |             |            |
|            |              |    receiving |             |            |
|            |              |     asthma   |             |            |
|            |              |              |             |            |
|            |              |    follow-up |             |            |
|            |              |              |             |            |
|            |              |    according |             |            |
|            |              |     to       |             |            |
|            |              |     protocol |             |            |
+------------+--------------+--------------+-------------+------------+
| **Primary  |              |              |             |            |
| Entities** |              |              |             |            |
|            |              |              |             |            |
| -          |              |              |             |            |
|    Service |              |              |             |            |
|     Unit   |              |              |             |            |
|            |              |              |             |            |
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|     Staff  |              |              |             |            |
|            |              |              |             |            |
| -          |              |              |             |            |
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|     Unit   |              |              |             |            |
|     Public |              |              |             |            |
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|     Staff  |              |              |             |            |
|            |              |              |             |            |
| -   Area   |              |              |             |            |
|     Public |              |              |             |            |
|     Health |              |              |             |            |
|     Staff  |              |              |             |            |
|            |              |              |             |            |
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|     Unit   |              |              |             |            |
|     Env    |              |              |             |            |
| ironmental |              |              |             |            |
|     Health |              |              |             |            |
|     Staff  |              |              |             |            |
+------------+--------------+--------------+-------------+------------+
|            |              |              | *           |            |
|            |              |              | *Learning** |            |
|            |              |              |             |            |
|            |              |              | -   Site    |            |
|            |              |              |             |            |
|            |              |              |   surveyors |            |
|            |              |              |     gain    |            |
|            |              |              |             |            |
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|            |              |              |     and     |            |
|            |              |              |     skills  |            |
|            |              |              |     to      |            |
|            |              |              |             |            |
|            |              |              |    identify |            |
|            |              |              |             |            |
|            |              |              |   exposures |            |
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|            |              |              |    Standard |            |
|            |              |              |             |            |
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|            |              |              |     asthma  |            |
|            |              |              |             |            |
|            |              |              |   follow-up |            |
|            |              |              |             |            |
|            |              |              |    protocol |            |
|            |              |              |     becomes |            |
|            |              |              |     part of |            |
|            |              |              |             |            |
|            |              |              |    clinical |            |
|            |              |              |     culture |            |
+------------+--------------+--------------+-------------+------------+
| **         | **Training   |              |             |            |
| Partners** | and          |              |             |            |
|            | Education**  |              |             |            |
| -   Tribal |              |              |             |            |
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|            |     p        |              |             |            |
| Department | resentations |              |             |            |
|            |     to       |              |             |            |
| -   EPA    |              |              |             |            |
|     Grant  |    potential |              |             |            |
|     Co     |     partners |              |             |            |
| ordinators |              |              |             |            |
|            | -   Develop  |              |             |            |
| -          |              |              |             |            |
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|            |              |              |             |            |
|   Partners |    materials |              |             |            |
|            |     to hand  |              |             |            |
| -          |     out to   |              |             |            |
| Elementary |     affected |              |             |            |
|     Sc     |              |              |             |            |
| hools/Head |  individuals |              |             |            |
|     Start  |     and      |              |             |            |
|            |     their    |              |             |            |
| -   Area   |     families |              |             |            |
|     HPDP   |              |              |             |            |
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| oordinator |     persons  |              |             |            |
|            |     doing    |              |             |            |
| -          |     site     |              |             |            |
|  Community |     visits   |              |             |            |
|     health |     (CHRs,   |              |             |            |
|     repre  |     EHS      |              |             |            |
| sentatives |     staff,   |              |             |            |
|            |     Public   |              |             |            |
| -   IHS    |     Health   |              |             |            |
|            |     staff)   |              |             |            |
|    Bemidji |              |              |             |            |
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|            |              |              |             |            |
|   Office/E |   clinicians |              |             |            |
| nvironment |     on       |              |             |            |
|     Health |     asthma   |              |             |            |
|            |              |              |             |            |
|   Services |   management |              |             |            |
|            |     protocol |              |             |            |
| -   County |              |              |             |            |
|            |              |              |             |            |
| Sanitarian |              |              |             |            |
+------------+--------------+--------------+-------------+------------+
|            |              |              |             | *          |
|            |              |              |             | *Results** |
|            |              |              |             |            |
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|            |              |              |             |            |
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|            |              |              |             |  effective |
|            |              |              |             |     public |
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|            |              |              |             |     system |
|            |              |              |             |            |
|            |              |              |             | -   Fewer  |
|            |              |              |             |     visits |
|            |              |              |             |     to     |
|            |              |              |             |            |
|            |              |              |             |   hospital |
|            |              |              |             |     due to |
|            |              |              |             |     e      |
|            |              |              |             | nvironment |
|            |              |              |             | al-related |
|            |              |              |             |     upper  |
|            |              |              |             |            |
|            |              |              |             | respirator |
|            |              |              |             |     dise   |
|            |              |              |             | ase/asthma |
|            |              |              |             |            |
|            |              |              |             | -          |
|            |              |              |             |   Improved |
|            |              |              |             |     health |
|            |              |              |             |     of     |
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|            |              |              |             | opulations |
+------------+--------------+--------------+-------------+------------+
|            |              | -   \#       |             |            |
|            |              |     persons  |             |            |
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|            |              |     to       |             |            |
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|            |              |     visits   |             |            |
|            |              |              |             |            |
|            |              | -   Ele      |             |            |
|            |              | mentary/Head |             |            |
|            |              |     Start    |             |            |
|            |              |     school   |             |            |
|            |              |     visits   |             |            |
|            |              |              |             |            |
|            |              | -   \# of    |             |            |
|            |              |     families |             |            |
|            |              |              |             |            |
|            |              |    receiving |             |            |
|            |              |     home     |             |            |
|            |              |              |             |            |
|            |              |   evaluation |             |            |
|            |              |     and      |             |            |
|            |              |     c        |             |            |
|            |              | orresponding |             |            |
|            |              |              |             |            |
|            |              |  educational |             |            |
|            |              |              |             |            |
|            |              |    materials |             |            |
|            |              |              |             |            |
|            |              | -   \# of    |             |            |
|            |              |              |             |            |
|            |              |   clinicians |             |            |
|            |              |              |             |            |
|            |              |   instructed |             |            |
|            |              |     on       |             |            |
|            |              |              |             |            |
|            |              | standardized |             |            |
|            |              |     asthma   |             |            |
|            |              |              |             |            |
|            |              |    follow-up |             |            |
|            |              |     protocol |             |            |
+------------+--------------+--------------+-------------+------------+
|            |              |              | *           |            |
|            |              |              | *Learning** |            |
|            |              |              |             |            |
|            |              |              | -   Know    |            |
|            |              |              |             |            |
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|            |              |              |             |            |
|            |              |              |   locations |            |
|            |              |              |     of      |            |
|            |              |              |             |            |
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|            |              |              |     factors |            |
|            |              |              |     to      |            |
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|            |              |              |             |            |
|            |              |              | -   Know    |            |
|            |              |              |     com     |            |
|            |              |              | munity-wide |            |
|            |              |              |     trends  |            |
|            |              |              |     in      |            |
|            |              |              |             |            |
|            |              |              |  home-based |            |
|            |              |              |     (or     |            |
|            |              |              |     other   |            |
|            |              |              |             |            |
|            |              |              |    location |            |
|            |              |              |     where   |            |
|            |              |              |             |            |
|            |              |              | significant |            |
|            |              |              |     time is |            |
|            |              |              |     spent   |            |
|            |              |              |     -- e.g. |            |
|            |              |              |     school) |            |
|            |              |              |             |            |
|            |              |              |    exposure |            |
|            |              |              |     to      |            |
|            |              |              |     disease |            |
|            |              |              |     agents  |            |
+------------+--------------+--------------+-------------+------------+
|            | **Case       |              |             |            |
|            | Review and   |              |             |            |
|            | Site         |              |             |            |
|            | Survey**     |              |             |            |
|            |              |              |             |            |
|            | -   Past     |              |             |            |
|            |     three    |              |             |            |
|            |     years'   |              |             |            |
|            |     medical  |              |             |            |
|            |     record   |              |             |            |
|            |     review   |              |             |            |
|            |     to       |              |             |            |
|            |     identify |              |             |            |
|            |     cases    |              |             |            |
|            |              |              |             |            |
|            | -   Database |              |             |            |
|            |              |              |             |            |
|            |  development |              |             |            |
|            |     to       |              |             |            |
|            |     record   |              |             |            |
|            |              |              |             |            |
|            | demographics |              |             |            |
|            |     and      |              |             |            |
|            |              |              |             |            |
|            | contributing |              |             |            |
|            |     factors  |              |             |            |
|            |              |              |             |            |
|            | -   GIS map  |              |             |            |
|            |     homes of |              |             |            |
|            |     cases    |              |             |            |
|            |              |              |             |            |
|            | -            |              |             |            |
|            | Develop/Find |              |             |            |
|            |     home     |              |             |            |
|            |     survey   |              |             |            |
|            |     tool     |              |             |            |
|            |              |              |             |            |
|            | -   Contact  |              |             |            |
|            |     affected |              |             |            |
|            |              |              |             |            |
|            |  individuals |              |             |            |
|            |              |              |             |            |
|            | -   Survey   |              |             |            |
|            |     homes    |              |             |            |
|            |     for      |              |             |            |
|            |     possible |              |             |            |
|            |              |              |             |            |
|            |    stressors |              |             |            |
|            |     and      |              |             |            |
|            |     asthma   |              |             |            |
|            |     triggers |              |             |            |
|            |     (with    |              |             |            |
|            |     permis   |              |             |            |
|            | sion/buy-in) |              |             |            |
+------------+--------------+--------------+-------------+------------+
| Medical    |              |              |             |            |
| Records    |              |              |             |            |
+------------+--------------+--------------+-------------+------------+
|            |              | -   \# of    |             |            |
|            |              |     cases    |             |            |
|            |              |              |             |            |
|            |              |   identified |             |            |
|            |              |     and      |             |            |
|            |              |              |             |            |
|            |              |    contacted |             |            |
|            |              |              |             |            |
|            |              | -   \# of    |             |            |
|            |              |     site     |             |            |
|            |              |     vi       |             |            |
|            |              | sits/surveys |             |            |
|            |              |              |             |            |
|            |              | -   \# of    |             |            |
|            |              |     home     |             |            |
|            |              |     sites    |             |            |
|            |              |     GIS      |             |            |
|            |              |     mapped   |             |            |
|            |              |     partners |             |            |
+------------+--------------+--------------+-------------+------------+
| U.S.       |              |              |             |            |
| Public     |              |              |             |            |
| Health     |              |              |             |            |
| Service    |              |              |             |            |
| Intern     |              |              |             |            |
|            |              |              |             |            |
| (COSTEP)   |              |              |             |            |
+------------+--------------+--------------+-------------+------------+

# PROJECT OBJECTIVES/DESCRIPTION/DELIVERABLES:

####### ***Program Goal:*** To reduce the rate of asthma attacks due to environmental exposures

####### ***Health Problem:*** Once a patient presents to the clinic with an asthma attack, the exposures to environmental respiratory disease agents are not identified and addressed through effective intervention. Therefore, the patient returns to being exposed to the disease agent.

####### ***Outcome Objective:*** By December 2008 repeat clinic presentations due to asthma attacks will be reduced by 30% through a sustainable and efficient process for following-up on cases.

####### ***Determinant:*** The number of follow-up surveys/site visits.

***Impact Objective:*** The number of cases of asthma attacks that are
followed-up (clinical protocol standards/home survey) will increase by
50% by December 2008. Follow-up will have to be a team approach since no
single program has the resources to perform the follow-up program alone.

####### ***Contributing Factors:***

1.  [Lack of personnel and funding resources:]{.underline} Indian Health
    Service is significantly under funded, and American Indians are not
    getting all of the services and the medical care that they need,
    especially in regards to primary prevention. According to the Center
    for Medicare and Medicaid Services (CMS), per capita spending has
    grown steadily over the past decade to nearly \$8,000 through
    Medicare and \$4,500 through Medicaid, while IHS funding has
    remained almost flat at \$2,000.

2.  [RMM methodology:]{.underline} The Office of Environmental Health
    and Engineering in the IHS adopted a methodology for tracking worker
    efficiency called "RRM." This methodology determines the workload
    for an environmental health specialist and a budget is created based
    on the methodology. Almost all of the activities tracked are
    environmental surveys leaving a worker little to no time to perform
    problem-solving activities or other services not listed in the RRM
    methodology, such as follow-up to cases with suspected environmental
    etiologies.

3.  [Low awareness and concern]{.underline}: the importance of
    remediation of disease agent exposure to prevent on-going illness
    (primary prevention) is not fully appreciated by the clinical
    personnel and the community. The dearth of funding has historically
    resulted in a reduction in environmental health services, and other
    primary preventative medical services, prior to reduction in
    secondary and tertiary health services. This has effectively
    eliminated the voice of the environmental health practitioner whose
    job it is to maintain awareness of environmentally-related illness
    among clinical staff.

4.  [Lack of clinical policies and procedures:]{.underline} Policies and
    procedures designed to activate a follow-up response to
    environmentally-related illnesses or to manage asthma cases in
    general are not in place. Due to the pressures on overburdened
    staff, formal follow-up policies have not been developed and
    implemented.

5.  [Communication:]{.underline} The community health clinic and the IHS
    health clinic fail to communicate on health events affecting Native
    American patients. Namely, when a Native American patient reports to
    the community emergency room (ER) for a possible asthma-related
    illness, the patient is treated and released with no communication
    to the IHS clinic. Therefore, no follow-up by an IHS healthcare
    provider is possible. Also, once an IHS provider does see a patient,
    that provider should communicate the need for a home assessment for
    asthma triggers to the Tribal EHS department.

####### ***Process Objectives:*** By June 2008: With input from clinicians, environmental health personnel, executives, and other stakeholders, a policy and procedure is developed for following-up on asthma attacks with environmental etiologies. This follow-up would include the following:

1.  Communication between the community health center and the
    appropriate IHS provider once they treat a patient for an
    asthma-related illness.

2.  The IHS healthcare provider utilizes a standardized patient
    management protocol (such as the *Global Strategy for the Management
    and Prevention of Asthma*) and reschedules the patient for follow-up
    visits.

3.  The IHS healthcare provider communicates to the Tribal Environmental
    Health Department that a home assessment for asthma triggers should
    occur. This may be formalized through a "doctor's order" format,
    whereby the patient is given written orders to have their home
    assessed.

4.  Certain asthma interventional items, such as dust mite covers for
    pillows, will be determined to be Durable Medical Equipment (DME)
    thereby allowing it to be reimbursable by Medicare/Medicaid.

# METHODOLOGY:

*Event and Activities*

**Event:** Develop an asthma action team consisting of a coalition of
various key partners

**Activities:**

-   Partners were contacted and invited to join the Asthma Action Team.
    Such partners included the following:

    -   Tribal Office of Environmental Health

    -   IHS Area Health Promotion and Disease Prevention Coordinator

    -   EPA Montana Indian Country CARE (Community Action for a Renewed
        Environment) Project Director

    -   IHS Clinic Chief Pharmacist

    -   Community health clinic personnel

    -   Local County Sanitarian

    -   Tribal leadership

    -   Head Start

    -   Local Schools

    -   Bemidji Area IHS Environmental Health Services

-   The Tribal Health Director was given a presentation on asthma and
    this project in order to gain his support and the support of the
    Tribal EHS department

**Event:** The age-adjusted period prevalence rate of asthma-related
visits to the IHS clinic for August 2006 through August 2007 will be
determined

**Activities:**

-   Medical records were reviewed for a one-year time frame to identify
    asthma cases

-   The age-adjusted prevalence was calculated and charts were developed
    using Microsoft Excel software

**Event:** Development of survey tools and educational materials

**Activities:**

-   A survey tool will be developed or an existing one will be adopted

-   The Indian Country CARE Director coordinated the development of
    educational materials (asthma kits) to be disseminated at schools
    and other community events

-   A Community-based workshop was held featuring Community Leadership
    Training (CLT) consultants, who specialize in mobilizing community
    leaders toward interventions to reduce airborne disease agents. This
    was also coordinated by the Indian Country CARE Director

-   The homes of asthma cases were GIS mapped in order to facilitate
    home assessments and to document their location for future study
    considerations

**Event:** Development of clinical follow-up policies and protocols

**Activities:**

-   Existing policies and protocols will be reviewed and updated

-   Clinical partners were given a presentation on asthma and this
    intervention project in an attempt to gain participation in policy
    and procedure development

-   Dust mite covers were declared Durable Medical Equipment (DME),
    thereby allowing it to be charged to Medicare/Medicaid so that the
    homeowner does not have to bear the cost

# NEXT STEPS:

The next steps for the successful implementation of this project are as
follows:

1.  Ensure the clinical protocol for asthma management is written,
    approved, and followed. This will be a challenging, yet critical
    element of the entire project. To persuade overworked clinicians to
    adopt a new process is difficult partly due to their resistance to
    change, since change seems like more work. Understanding this, the
    Chief Pharmacist and the author plan to tread carefully and provide
    a clear background on the issue demonstrate the cycles that are
    operating that are, in fact, increasing their burden. As an element
    of the protocol, we will continue working to establish communication
    between the community ER and IHS clinicians; and between the IHS
    clinicians and the Tribal EHS department.

2.  Continue building the Asthma Action Team by conducting regularly
    scheduled monthly teleconferences and continuing to invite key
    players to participate.

3.  The Community Leaders Training workshop produced a document that
    delineates collaborative interventions between community leaders. We
    hope to use that document to continue building partnerships and
    allowing community leaders to participate in asthma interventions.

4.  Training on home assessments. It is important to develop a cadre of
    individuals who can perform the assessments. Besides the Tribal EHS
    department, some potential partners who could receive home
    assessment training and possibly perform the assessments are Indian
    Country CARE partners, public health nurses, community health
    representatives, and Tribal Housing Authority personnel.

5.  Finally, a re-evaluation of the asthma prevalence and an evaluation
    of the entire asthma management and intervention system should take
    place during December 2008.

# CONCLUSIONS:

# The overlying theme of this successful intervention is partnership and communication. Successful public health interventions are not achieved easily and may require simultaneous and collaborative action by several entities and individuals in order to be effective. By bringing all the partners together to discuss an issue in which they all play a role allows exposure to varying perspectives. This gives the entire team a "big picture" of the issue they would otherwise fail to see and facilitates creative interventions that incorporate all the elements present within the issue.

In this project we have been discussing asthma and its interventions;
however, all the concepts presented in this project can and should be
used for virtually all diseases of environmental etiology. Take, for
instance, community-associated methicillin resistant *Staphylococcus
aureus* (CA-MRSA). Rates of infection by this organism are rising in
Indian Country and, while scientific certainties are lacking as yet, we
postulate that contributing factors may be overcrowding and poor
environmental hygiene in the home. To address this issue would require a
virtually identical two-tiered intervention mechanism as asthma: 1)
clinical protocols, and; 2) environmental health services. These two
interventional arms would be linked through a formalized communication
and feedback process.

# LEADERSHIP DEVELOPMENT OPPORTUNITIES:

####### ***Gary Carter***

Virtually all elements of the Environmental Public Health Leadership
Institute (EPHLI) have provided benefits, skills, and knowledge useful
in leading meaningful environmental public health efforts. First, EPHLI
has truly enlightened me about my leadership strengths and weaknesses.
The Skillscope^®^ and Meyers-Briggs Type Indicator (MBTI^®^) reports
were extremely useful tools in my self-evaluation. I have earnestly used
the information gleaned from these reports to improve my personal
leadership skills and have been enjoying positive results. Second, I
found Systems Thinking to be a powerful tool to be used in seeking
solutions to tough environmental public health issues, and almost all of
them are tough. Third, the professional network is in itself an
invaluable tool to addressing environmental public health problems. The
future of environmental public health is based in collaborative
partnerships to solve problems, and having met so many impressive
professionals whose expertise can be accessed with a telephone call or
email message is worth its weight in gold.

# ABOUT THE EPHLI FELLOW(s)

Lieutenant Commander Gary Carter is a Commissioned Corps Officer with
the U.S. Public Health Service and is currently attached to the Indian
Health Service in Billings, Montana. He functions as the Billings Area
IHS Institutional Environmental Health Officer focusing most of his
efforts on occupational health and safety, and emergency planning for
healthcare facilities.

# REFERENCES

1.  United States Commission on Civil Rights. Quiet crisis: federal
    funding and unmet needs in Indian Country. Washington, DC.; 2003.
    Available at: <http://www.usccr.gov/pubs/na0703/na0204.pdf>.
    Accessed December 12, 2007.

2.  Senge P, Kleiner A, Roberts C, Ross RB, Smith BJ. *The Fifth
    Discipline.* New York: Currency Doubleday; 1994.

3.  Osaki, C., eds.. *10 Essential Services of Environmental Health.*
    Northwest Center for Public Health Practice, Universtiy of
    Washington School of Public Health and Community Medicine, Seattle;
    2004.

4.  Institute of Medicine. The future of public health. Washington, DC:
    National Academy Press, 1988.

5.  U.S. Department of Health and Human Services. Office of Disease
    Prevention and Health Promotion. (n.d.). Healthy People 2010.
    Available at: <http://www.health.gov/healthypeople/> . Accessed
    January 3, 2008.

6.  CDC Health Protection Goals. Available at
    <http://www.cdc.gov/about/goals.htm>. Accessed January 3, 2008.

7.  Institute of Medicine. *Clearing the Air: Asthma and Indoor
    Exposures*. Washington, D.C.: National Academy Press: 2000.
    Available at: <http://www.iom.edu/CMS/3793/5511.aspx>. Accessed on
    September 21, 2007.

8.  Global Initiative for Asthma: Asthma Management and Prevention: A
    Practical

Guide for Public Health Officials and Health Care. Available at:
<http://www.ginasthma.com/>. Accessed on August 24, 2007.

9.  [Norwood
    R](http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term="Norwood R"%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVAbstractPlus),
    [Meyer
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    Factors Associated with Health Care Professionals\' Choice of
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    2007;172(10):1058-64.

10. National Strategy to Revitalize Environmental Public Health
    Services. Available at:
    <http://www.cdc.gov/nceh/ehs/Docs/nationalstrategy2003.pdf>.
    Accessed on January 8, 2008.

11. Environmental Health Competency Project: Recommendation for Core
    Competencies for Local Environmental Health Practitioners. Available
    at:
    <http://www.apha.org/programs/standards/healthcompproject/corenontechnicalcompetencies.htm>.
    Accessed on January 8, 2008.