Problem Statement: 300,000 Contra Costa residents live in a census tract that ranks in the 95th percentile or higher of asthma Emergency Department (ED) rates statewide. This is the highest number of people in any county in the state and the fourth highest by percent of County residents in the state. An estimated 4,950 people visit the ED for asthma each year in the County and they disproportionately are of lower socio-economic status and African-American than the general population. Asthma exacerbations are largely avoidable, but significant portions of the federally recommended asthma care guidelines (home-based education and remediation of asthma triggers) are not traditionally covered by Medicaid or included in traditional clinical care.
Proposal: The initiative expands upon existing asthma home visiting efforts in two ways: 1) by incorporating home assessment and remediation service provision into current program efforts, and 2) developing operational proficiency in a home-based delivery model, which can serve as a blueprint for securing sustainable funding to address social determinants of health from the healthcare, housing, and energy sectors. The initial phase of the initiative targets 50 high-risk members (adults and children) on the Contra Costa Health Plan (CCHP) over one year with a coordinated home-based delivery model that supplements traditional clinical care. Additional phases may include a) expansion of the target population to include low- and middle-income residents (i.e. those not on CCHP) through partnerships with BayREN and other insurers or b) expansion of services to include additional healthy home measures for other health issues (e.g. COPD, trip/falls).