Supporting Asthma Management Behaviors in Aging Adults

Older asthmatics experience worse outcomes than younger adults, especially if they identify
as Latino or African-American. Several factors contribute to worse outcomes in these
populations including frailty, cognitive impairment, managing multiple chronic diseases and
multiple daily medications, low health literacy and English proficiency, high healthcare
costs, and misunderstandings about asthma. To our knowledge, there are no programs designed
to help older asthmatics manage their illness. In order to address these factors two emerging
patient-centered strategies, clinic- and home-based care coordination and self-management
support led by an Asthma Care Coach (ACC) and a community health worker (CHW), respectively,
will be tested. These strategies will be combined a clinician-centered strategy, use of
electronic medical record (EMR)-based asthma decision support that guides medication
prescribing, basic counseling, and provision of asthma action plans.

Specific aims are:

1. To compare the effectiveness of (1) ACC/clinic- or (2) CHW/home-based asthma care
coordination and self-management support with (3) no care coordination/self-management
support (usual care) for improving asthma-related outcomes;

2. To identify subsets of individuals who have greater benefit from home-based care
coordination and self-management support compared to clinic-based support.

A 3-arm, randomized trial will be conducted among 450 adult asthmatics ages 60 and older at
primary care practices in East and Central Harlem and the South Bronx. All patients,
regardless of assignment, will receive care from primary care providers (PCP) with access to
the EMR-based asthma decision support. Patients in the ACC and CHW arms will be assessed for
barriers to asthma control and will receive support specifically tailored to the identified
barriers, including those arising from physical, mental, social/economic, or cognitive
issues. Program participation will be 12 months, during which the ACCs and CHWs will also
work with the patients' PCPs to optimize care. The study team will engage stakeholders
(patients and caregivers, clinicians, community-based organizations, others) to develop and
prepare study materials and protocols. In addition to studying patient outcomes, the process
of implementing these models of care will be evaluated and documented.

Patients in the ACC and CHW arms will have similar asthma outcomes (asthma control, quality
of life, use of urgent care, appointment keeping, medication adherence, use of asthma actions
plans). Compared to usual care, patients in the ACC and CHW arms will perform better on these
outcomes. Patients with more severe asthma and those at greater risk of missed clinic
appointments because of physical or cognitive impairment and psychosocial issues (e.g.,
substance abuse, mental illness) will be more likely to benefit from the CHW/home-based
intervention.

Inclusion Criteria:

- ages ≤60 years

- physician diagnosis of asthma

- English- or Spanish-speaking

Exclusion Criteria:

- physician diagnosis of Chronic Obstructive Pulmonary Disease (COPD) or other chronic
lung condition

- ≤15 pack-years

- enrollment in another asthma self-management program