Model Proposals - Circle Family Care's Request to the VNA

One of VNA's grantmaking priorities is to fund programs which can demonstrate objective measures of their impact on a population or problem. In addition, we enjoy funding programs which offer home-based health services, as they allow for the kind of broad-ranging and individualized care that is likely to achieve lasting impact.

Circle Family Care (CFC) addresses well both these funding priorities in the proposal presented below.

This proposal was for a renewal grant in support of CFC's Home Visiting Nurse Project, an outreach program to improve the health of those in the Austin community suffering from asthma, diabetes and other chronic diseases. The proposal does an excellent job of establishing the need for the program, the capability of the agency to address it, and, most especially, the clearly defined means by which its impact will be measured.

The proposal was approved in full by the VNA Foundation Board at its February 7, 2002 board meeting. We are pleased to offer it as the Proposal of the Quarter for the quarter ending March 31, 2002.

Organization's mission, history and overall goals

Circle Family Care (CFC), 5002 W. Madison St., Chicago, IL 60644, (773) 379-1000. Incorporated in 1977, CFC provides medical, educational, social, and behavioral health and human services from a Christian approach, targeting the under-served populations on Chicago's West Side. Services include foster care, individual and family counseling, family support services, art therapy, teen outreach, psychotherapy, case management, medical services to the homeless, psychosocial rehabilitation, immunizations, complete family practice, HIV/AIDS outreach and health education services.

Linkages
CFC's physicians are on staff at West Suburban, Oak Park, Bethany, Loretto and the University of Illinois hospitals. The Chicago Department of Health, Office of Mental Health/Illinois Department of Human Services, Illinois Department of Children and Family Services and the United States Bureau of Primary Health Care license the agency. CFC is accredited by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO), is currently working through another accreditation process with the Council on Accreditation (COA) and provides services on a sliding fee scale without regard to gender, race, religion or financial resources.

CFC has participated in many health initiatives for HIV prevention with the Westside Minister's Coalition, a consortium of churches on Chicago's West Side. CFC has participated in health screening or health education at many Westside Churches. CFC collaborates with many community organizing groups, and coalitions, including Bethel New Life, Westside Health Authority, Northwest Austin Coalition Community, South Austin Community Council and Illinois Health Coalition for Communities of Color. The "Healthy Lifestyles" project with Westside Health Authority involves assisting citizen leaders in improving health through support and increased knowledge. CFC is a member of the Cook County Community Health Council (CCCHC), a consortium of health care providers, community leaders, social service agencies and public health administrators working together on health issues. The Chicago Health Department, through it's Austin Cardiovascular Project, "Project Active" has helped to develop walking groups to encourage lifestyle changes through promotion of exercise, and goal setting. The Neighborhood Referral Program with Cook County Hospital, provides free medications, laboratories and specialty services to chronically ill patients. CFC provides prenatal and well childcare through affiliation with the Chicago Department of Health, Maternal Child Health.

CFC has had an educational affiliation with the University of Illinois since 1994. This includes training of public health nursing, medicine, pharmacy, public health and nutrition students. CFC is currently contracted for UIC Midwifery Service, pharmacy, pediatric, nurse practitioner and nutrition services. Partnerships with local schools include smoking cessation education (Tar Wars), asthma education (Open Airways) and Hepatitis B vaccinations through the "Adopt a School program" with the West District Health Council of CCCHC. Further, CFC is forming a school based clinic with Flower's Academy in partnership with the Chicago Public Schools. Clinical research including "Promoting Positive Parenting Study" through Children's Memorial Hospital (National Institute of Mental Health), "Peer Education in Pregnancy Study" with the University of Illinois (National Institute of Environmental Health) to utilize peer educators to reduce triggers and delay the onset of wheezing in children. The Americorps Program strengthened asthma and diabetic education, case finding and education through the development and updating of patient registry.

Current Programs
Circle Family Care's programs serve approximately 13,085 clients annually at six locations. CFC provides high quality comprehensive health services, including disease prevention and health promotion. As a Federally Qualified Health Center (FQHC) providing primary care in a medically underserved community, CFC develops an annual health care plan, to provide comprehensive care within the community. Patients who may not otherwise receive care receive holistic culturally sensitive primary health care.

The executive director, physicians, and many staff live within community and have a long experience working within communities. The mobile health team provides interdisciplinary health care within a flexible health care setting. It brings health care to where people are living and adapts care to individuals needs. The Early Intervention Program (IEP) involves an interdisciplinary team, which provides high quality, empathetic primary care to individuals infected with the HIV virus.

High quality asthma care, including the development of educational materials which cover all aspects of asthma care including trigger control, prevention regimes, action plans for asthma exacerbations. Systems have been developed for identifying asthma patients, increasing the intensity of asthma education and the relevancy of this teaching in the patient's self care. Monthly asthma classes have also been formed.

A diabetes team was formed to prevent complications of diabetes and to provide proactive care for diabetics through the Bureau of Primary Health Diabetes Collaborative. Changes have been put in place to redesign health care systems to improve diabetic control including a diabetic registry for patient tracking, follow-up, and recall and the formation of monthly diabetes group visits to increase diabetic education, self management skills and screening. With empowerment monies from the City of Chicago, access to care was increased, through extended clinic hours, outreach into the community and enrollment into Kidcare (Child Health Insurance Program).

Needs Assessment
The Austin community is reported by the Department of Children and Family Services (DCFS) as having a disproportionately high number of individuals living at one, two and three times below the poverty rate compared to other "like" communities in the city of Chicago. Risk factors such as high unemployment, lower educational level, and low family income increase the number of barriers toward the use of preventative health care. These patients are also more vulnerable to health and social problems. The Austin community is designated by the Chicago Department of Health as a medically under served area.

There is a large racial disparity of diabetes and asthma incidence, disability and mortality rates for African Americans. Between 1982 and 1991, asthma cases increased by over 48%, with a higher increase among African American and Hispanic populations. Blacks have an asthma rate that is 6 times greater than for whites. Asthma deaths are disproportionately higher in poor neighborhoods and among African Americans. The death rate from asthma is 3 times higher for blacks then for whites. Asthma deaths can be largely preventable with proper management and health care access.

African Americans with diabetes are more likely to develop diabetes complications and experience greater disability from the complications than white Americans with diabetes. Death rates for people with diabetes are 27 percent higher for blacks compared with whites. Death due to diabetes in Chicago in 1996 was 19/100,000. In the Austin community this rate is 28/100,000, ranking the 12th worst outcomes in the city. The relative risk of dying from diabetes in the Austin community is 1.5 times the rest of the city of Chicago. Compared with white Americans, African Americans experience higher rates of diabetes complications such as eye disease, kidney failure, and amputations. They also experience greater disability from these complications. Proper diabetes management can reduce factors that influence these complications, such as high blood glucose levels, abnormal blood lipids, high blood pressure, and cigarette smoking.

Population served
Currently, 450 diabetics and 300 asthmatics have been identified who are patients at CFC. Those persons who have poor control, as measured by lab values or self-report, decreased primary care use and increased emergency room use will be referred to the program.

Project Description
Two hundred patients with diabetes and asthma will be identified, evaluated and managed by a public health nurse. A public health nurse will provide home visits to high-risk chronically ill patients with poor diabetic or asthma control who do not receive regular health care. These families will be identified by use of the diabetic and asthma registry and hospital rounding sheets. This program broadens existing primary care services to include home assessment, education, support and follow-up for chronically ill patients.

Public Health Nursing visits will enhance patient communication, increase empowerment and support of the family, increase knowledge of self-care and reduce risks within the environment. It will increase access to health care, relevancy of health care to the patient, and coordination of care. Services will stress home assessment, prevention of complications, problem solving, case management, and education for self management and lifestyle changes to patients with diabetes and asthma.

Health care delivery will be strengthened through improved continuity of care, coordination of services and knowledge of the context of the patient's health. Eliminating confusion of how to use the health care system and where those services exist, what to ask health professional, and the processes of accessing care, will increase early access to care. This will increase patient compliance and greatly enable the patient's sense of control with their care. Access to healthcare will be improved by strengthening linkages between the clinic and the home. Increased knowledge of the patient helps health care providers understand the context of the home and apply this context to providing more relevant health care. Better health care delivery will exist through collaborative relationships between the patient, the public health nurse, the clinic nurse, the health care provider, specialist and community agencies.

By exploring barriers to self-management and assisting the patient with problem solving, improved health outcomes will occur. The nurse will evaluate the family's physical, emotional, social, economic and environmental status and determine what barriers to healthy behaviors exist. Individualized health education will increase the patient's knowledge, and problem-solving ability for managing their disease and preventing complications. By providing emotional and educational support, patients will feel more engaged in self-management, and follow through with regular use of health care. Self-management goals, which are set with the patient and nursing interventions, will be tailored to the family's individual needs and abilities. Exploring issues within the patient's home and including the patient in determining the health plan will increase patient acceptance of a health care plan to decrease behavioral, physical and environmental risk factors. This will improve health outcomes in our patients and reduce health disparities in diabetic and asthma outcomes seen within poor black communities.

Implementation Strategies

Goal 1:

200 patients with diabetes will have documented self-management goals, improved skills in self care and improved diabetic control. Objectives:

• Of the targeted patients, all will have documented self-management goals and receive and understand information on the essential elements of diabetic care as outlined by the American Diabetic Association (ADA).
• Of the targeted patients, all will receive information on home glucose monitoring and will receive a home glucose monitor. 90% of these patients will have a completed glucose diary.
• Of the targeted patients, all will be offered screening based on the ADA 2000 Guidelines, and 90% will receive this screening.
• Of the targeted patients, 90% will have improved diabetic control, as evidenced by a 10% decrease in their HbA1C.
• Of the targeted patients, all will have had a follow-up clinic visit within the last three months and utilize specialty referrals as needed.

Goal 2:

100 patients with asthma will have documented self-management goals, improved skills in self care and improved asthma control. Objectives:

• Of the targeted patients, all will have a documented self-management goal and receive information on the essential elements of asthma care, as outlined by the National Institute of Health.
• Of the targeted patients, all will receive information on peak flow monitoring, will receive a peak flow meter and return demonstrate it's use. 90% of these patients will have a completed peak flow diary.
• Of the targeted patients, all will have home triggers assessed and will be able to discuss trigger control in the home.
• Of the targeted patients, all will possess, understand and utilize an emergency action plan for asthma exacerbations. This will be measured by the patient presenting the action plan, being able to knowledgably discuss the action plan and utilizing the action plan in the event of an asthma exacerbation.
• Of the targeted patients, 90% will understand the use of asthma medications, possess the medications and a spacer, and administer the prevention medications as directed.
• Of the targeted patients, 90% will have improved asthma control, as evidenced by decreased symptoms, decreased emergency room use, less school or work days lost, and improved peak flow levels.
• Of the targeted patients, all will have had a follow-up clinic visit at least every three months and utilize specialty referrals as needed.

Time Frame
The Home Visiting Nurse Project will provide uninterrupted home visitation services upon the funding of this program. It will operate for one year, in hopes of renewable funding from VNA or other sources.

January - February 2002

• Upon notification of the grant, continue home visitation services with the existing public health nurse, Carolyn Samec.
• Purchase needed supplies, equipment and education materials, as needed.
• Continue to promote public health nursing services to Circle family Care staff, expand services to Gunnar clinic.

March- April 2002

• Identify additional patients through provider referral, asthma and diabetes registry, and hospital rounding sheets and managed care utilization review.
• Case conferencing with health care provider, and clinic nurses will occur ongoing.
• Ongoing evaluation of nursing interventions and patient outcomes based on objectives.
• Write final report for year one of project.

May - June, 2002

• Continue home visitation and clinic follow-up.
• Quarterly program evaluation based on patient outcomes shared with key staff.
• Feedback and adjustments to project as needed.

July - September 2002

• Increase caseload of families followed.
• Document nursing interventions, integrate home visit information into clinic processes, and monitor patient outcomes.

October - December 2002

• Initiate plans for project sustainability
• Evaluation of successes of program objectives.
• Prepare project final report

Program Methodology
The program goal and objectives will be achieved through a home visitation program to patients with asthma and diabetes. This program is designed to provide nursing care to increase knowledge and understanding of self-management, increase communication between patient and health care provider, and breakdown barriers to health care access. Public health nurses will provide outreach services utilizing standards set by American Nurses Association, American Diabetic Association and the National Institute of Health. They will also link patients with needed services within the community and encourage compliance and follow-up.

Key Staff
Ellen Barton, RN MS, Education Coordinator and Family Nurse Practitioner, will coordinate and evaluate this project, provide consultative and technical assistance, identify families in need of home visits and assist in staff training and orientation.

• Bernita Lee, RN, Nursing Supervisor will provide supervision and guidance to the public health nurse.
• Carolyn Samec, RN, BSN will continue to provide home health services to identified families, participate in case finding and follow up of patients. She will provide patient education, home assessment, case management, and provide needed referrals.
• Joyce Smith, MD, MPH, Medical Director, will provide medical and administrative support Collaboration with other agencies

Referrals will be made to specialists, as needed for screening and patient evaluation and treatment. Referrals will be made to assist the patient in overcoming risk factors for poor health. Services such as educational resources, job training and placement services, counseling services, and substance abuse treatment facilities. Enabling services through support groups, nutrition and cooking classes, exercise programs, recreational opportunities and specialty care will be offered when needed.

Sustainability
Circle Family Care requests your consideration of this proposal for funding of this Home Visiting Nurse Project. If funded, renewal of monies will be sought for year 3. A grant of $60,000 from the Visiting Nurses Association Foundation will continue to help us implement this innovative and important project.

Measure of effectiveness Information for measuring project outcomes will be gathered through a variety of evaluation tools. Health Care Utilization will include use of primary care, emergency room use, community referrals, specialty care, and the Home Visitation Nursing Process Record. A Nursing Process Log will track all patient home visits, measure nursing interventions, patient needs and measure family outcomes. Patient Education will measure essential elements of diabetic care, patient understanding by return demonstration, patient diaries of peak flow and glucose monitoring. Self Management will be measured by the existence of self management goals, assessing changes in behaviors such as medication use, diet and exercise modification, self monitoring and screening. Health Outcomes will be measured by patient self report, Clinical Measures Reports (chart audits), and an Asthma and Diabetic Patient Registry using Microsoft Access which will monitor the home care received by diabetic and asthmatic patients and document improved control. A Quarterly Report will be generated to provide feedback on how effectively targeted families are receiving care in the clinic and the home, and the impact of these visits on patient's health.

Criteria for success
The project's criteria for success will be to identify and provide public health nursing home visits to 200 patients with diabetes and asthma at risk for poor outcomes. Of those families contacted, all will receive family and environmental assessment, nursing interventions, referrals to appropriate resources, and evaluation of response to treatment. Patients will demonstrate improved skills in asthma and diabetic control. Improvements in home trigger control, lifestyle modifications, health maintenance, medication use, and utilization of referrals will be evidenced by the patient. Patients with diabetes and asthma will have better control of their diseases, less hospitalizations and improved health outcomes.

Expected Results
Families with diabetes and asthma receiving home services through the Home Visiting Nurse Program will experience improved continuity of care, including increased use of primary care services and reduced hospitalizations and emergency room use. Patients will adopt lifestyle changes to improve health, and receive recommended screening for early detection of complications. Families will be provided with needed resources to reduce risk factors for poor health, have improved problem solving abilities, and enhanced social support. Patients with diabetes and asthma will learn to control their diseases more effectively, feel more confident in caring for their health, and have fewer complications and better health outcomes.

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