Peers help Medicaid patients manage asthma

First step is understanding readiness to change

It’s difficult enough to get mainstream group-health patients to comply with an asthma management program. Imagine how much more difficult developing an effective asthma management program would be if your patients were homeless. One health plan finds recruiting community members to work as peer outreach specialists reduces barriers to care in Medicaid populations.

"To get people to comply with disease management plans, you have to establish a strong bond with them," says Gabrielle Reed, PhD, RN. Reed is an instructor of medicine in the division of health behavior research at the Washington University School of Medicine in St. Louis, which runs an asthma management program for Medicaid patients. "You can’t walk into the community we serve and be white and middle-class and hand down a medical prescription from on high," she says. "The people simply won’t hear you. Some are even homeless. They’re not ready to talk about asthma. We have to help them find housing first."

Washington University recruited young African American women with children to work with its asthma management program. "We hire interested women right out of the community. It’s neighbors helping neighbors, and it begins with the enrollment stage."

When children are admitted to the hospital for asthma, their names and telephone numbers are given to two older African American women who call the children’s families to explain the program and invite participation. "The voice on the phone is a recognizable voice. It’s comfortable to our moms," says Reed.

To encourage caregivers of asthmatic children to participate in the program, Washington University pays caregivers $10 for answering the program’s questionnaire.

"We randomize half the group into a treatment group," Reed says. Members in the treatment group are assigned a peer specialist. The peers visit caregivers at home and gather information to determine the caregiver’s stage of readiness to change.

Physicians and nurses from Washington University train the asthma management program’s peer outreach specialists in basic asthma management, signs and symptoms of an asthma episode, and the stages of readiness model of health behavior change pioneered by researchers at the University of Rhode Island in Warwick. (For a description of the five stages of readiness, see box, above. For ideas on determining a patient’s readiness stage, see story, p. 20.)

"When we first explain the stages of readiness to our peer specialists, they immediately respond to it. They say it’s so intuitive," notes Reed. "They easily sense which caregivers are ready to receive educational materials and make changes in their child’s asthma management and which aren’t. If they aren’t ready, we work on eliminating barriers to behavior change and moving them forward."

The Transtheoretical Model of Health Behavior Change cites five stages of readiness to make health-conscious changes in behavior. "If we pay attention to how ready people are to change, we don’t run the risk of patients tuning us out," says Reed.

Most of the research on the stages of readiness has revolved around health promotion programs. The key to successfully applying the model to disease management is carefully selecting the behaviors you target for change, notes Reed. "You have to select behaviors that will actually produce health changes in your population."

She suggests using focus groups to select those behaviors and also to "get your vocabulary right. When you finally get your patients to the point where they are interested in managing their asthma, it’s great to have teaching materials appropriate to the population," she continues. "And not only should the reading level and the language used be appropriate, but the illustrations should look like your target population."

Washington University targeted seven behaviors for its asthma management program. They include:

¤ Primary caregiver has a copy of child’s asthma action plan.
¤ All other caregivers have been made aware of the child’s asthma action plan.
¤ Primary caregiver gives rescue medications according to asthma action plan.
¤ Primary caregiver brings child in after four months for regular follow-up care.
¤ Primary caregiver eliminates or reduces child’s exposure to secondary smoke and cockroaches.

"Our moms recognize their child’s asthma symptoms," Reed says. "They know when their child is going to get bad, but they wait too long to give prescribed rescue meds, and the children end up in the emergency room."

To encourage caregivers to take action to prevent a severe asthma episode, peer specialists often accompany caregivers to their child’s physician’s appointment. "The peer specialist’s a role model to help caregiver’s communicate better with their child’s doctor," explains Reed. "Many of our caregivers have a tendency to go to their child’s appointments without really dialoguing with the doctor. They may hear all the asthma information and still go home and ask their grandmother what to do. The doctor may never know that the advice was never followed."

To make change even more difficult, Reed admits that many caregivers of children in the asthma management program have little control over their child’s physical environment. "We know we’re sometimes fighting an uphill battle with issues like secondhand smoke. Even if the mom doesn’t smoke, she may leave her child with a grandmother who smokes while she works. She needs her mother to baby-sit, and we come in saying, Don’t you realize that secondhand smoke is bad for your child?’" she says. "If peer specialists look at that mom’s face and see from her expression that she’s not ready to make that change, they start talking around that issue. They plant seeds of information. They challenge the moms to figure out how to make things work.

"Nobody makes changes unless they think they’re going to work," adds Reed. "Facts and figures don’t go over well until somebody believes you."