1015 West Lawrence Avenue
Chicago, Illinois 60640
Contact: Heidi Nelson
Phone: (773) 275-2060
Key words: residential program; mental
health;
case management; TB; asthma; housing
Note: Chicago Health Outreachs (CHO)
pilot study consisted of four major
subparts on the following CHO programs:
1) the Safe Haven Residential Mental
Health Program; 2) Connections Mental
Health Case Management Program; 3) Primary
Care Clinic TB Program; and 4) Asthma
Primary Care Services. To allow for
maximum clarity, each topic will be
discussed separately; therefore, there
are four reports for Chicago Health
Outreach.
#1: SAFE HAVEN RESIDENTIAL MENTAL HEALTH
PROGRAM OBJECTIVE
The purpose of this study was to examine
whether or not the provision of housing
in a safe environment and the support
of staff encouraged people to take psychotropic
medications and to participate in mental
health services.
METHODS
Safe Haven is a low demand, residential
program for difficultto- engage, severely
mentally ill persons with a history
of homelessness. The goal of the Safe
Haven program is to engage participants
in mental health services. The indicators
for medications and participation in
services were measured retrospectively
through chart review for the 13 month
period from the beginning of the program
(June 1996) through June 1997. A total
of 13 residents lived at Safe Haven
during this time, for varying lengths
of time. Medical records were reviewed
for information about sessions with
the psychiatrist and medications taken
before and during patients time at Safe
Haven. Attendance logs were reviewed
for participation in mental health services
offered at Access to Community Care
and Effective Services and Support (ACCESS),
including attendance at the ACCESS respite
center. The Safe Haven supervisor provided
demographic information; dates of stay
at Safe Haven; and information about
participants_ progress with medications.
The associate director of the residential
mental health programs, the director
of the ACCESS program, and the program
psychiatrist provided information about
participants progress in the program
and their housing status after leaving
the Safe Haven. Seven women and six
men comprised the study group, including
eight Black, three White, and two Hispanic
participants. Their average age was
40 years. During the 13 month period,
the average length of stay for the 13
residents was approximately five months
(155 days), and the median was approximately
2.5 months (79 days). Five of these
people were taking some medication at
the time they accepted housing at Safe
Haven. Outreach workers met participants
on the street or in shelters, and some
had already attended the respite center
and/or met with the psychiatrist.
RESULTS
Of the five people who came to Safe
Haven already taking psychotropic medications,
all of them continued taking medications
during the study period. One of these
people accepted intramuscular injections
only and no oral medications. The average
length of stay for this group was 82
days. On average, these people took
medications 88 percent of the days they
lived at Safe Haven. Of the eight people
who were not taking medications at the
time they came to Safe Haven, three
decided to begin taking medications.
Their average length of stay was 281
days. One of these people accepted injections
only and received injections for all
of his time at Safe Haven. One person
took medications on 25 percent of the
days and the other on 62 percent of
the days. Five people took no medications
while living at Safe Haven. Two of these
people actually decided to begin medications
but discontinued after 1 day. The average
length of stay for this group was 152
days. However, the range was very large,
and the median length of stay was only
14 days. The overall rate of Safe Haven
participants on medication for the study
period was eight per 13, or 62 percent.
The average and median percent of days
that the subjects were on medication
were 49 percent and 62 percent, respectively.
This rate cannot be considered compliance.
In some cases, several medications were
prescribed, and the patient accepted
some and refused others. For medications
taken several times a day, some doses
were missed, and sometimes days or weeks
were missed. Among these 13 people,
only three never accepted psychiatric
medical care from the programs psychiatrist.
The recommended number of sessions with
the psychiatrist is one per week, although
residents are not required to meet with
the psychiatrist and do not have weekly
appointments. For the ten people who
did accept psychiatric care, the average
percentage of weeks they met with the
psychiatrist was 19 percent, and the
median percentage was 17 percent. Only
two people never attended the respite
program at ACCESS. On average, Safe
Haven residents attended 40 percent
of the time (the median was 50 percent).
Daily attendance at the respite program
was recorded by ACCESS staff. Participants
were considered to be present as soon
as they came through the door. Respite
program activities include preparing
and eating lunch and other social activities.
DISCUSSION
Because the total number of Safe Haven
residents at the time of the study was
very small, frequencies have limited
usefulness. Another barrier to analyzing
the results is the lack of a control
group. Obviously, ethical considerations
prohibit withholding services from some
participants in order to draw conclusions.
Also, because the program had been accepting
residents for just over one year, it
was difficult to measure outcomes since
engagement in services can be a long-term
process. The provision of safe, low-stress
housing seems to have an impact on maintenance
of medications as well as on the decision
to take medications. Through engagement
in ACCESS mental health services prior
to accepting housing at Safe Haven,
five people had already begun medications,
and they remained medicated while at
Safe Haven. Non-adherence to medications
is common among homeless persons. It
is unlikely that these people could
have maintained such a high percentage
of days on medications (88 percent)
if they had been living on the street.
Similarly, the access to medications,
encouragement and monitoring that was
provided to residents made it possible
for three persons to decide to take
medications. For this difficult-to-engage
group, the number who decided to take
or maintain medications at all is significant.
Five individuals did not take medications
at Safe Haven. For three of these people,
the length of stay was very brief (one
person stayed only 2 weeks and two people
stayed only 4 weeks). Little time in
a supportive environment may have been
the reason that they did not make progress
on this goal. One woman who was at Safe
Haven for 45 weeks actually decided
to accept medication but became ill
upon taking the first dose and discontinued
the medication. Another person agreed
to take medications but discontinued
after one day. These two people apparently
realized their need to be medicated,
which may be the first step in medication
adherence. Engagement in psychiatric
services was low. It is unknown why
Safe Haven participants were reluctant
to meet regularly, or at all, with the
program psychiatrist. Perhaps meeting
with Safe Haven staff in an informal
manner where people live or with ACCESS
staff informally at the respite center
is more acceptable for these people
than meeting with a medical professional
one-on-one. Or perhaps, past experiences
with psychiatric care have left some
people afraid to engage in treatment
on this level. People_s reluctance to
be treated by a doctor highlights the
importance of the case management and
other on-site services provided at the
Safe Haven. Participation in mental
health programming through ACCESS was
widespread and fairly high. Almost all
people spent some time at the ACCESS
respite center, and for those people,
an average of 40 percent of the sessions
were attended. Again, for this difficult-to-engage
group of people, willingness to be involved
in any programming is encouraging. An
ultimate outcome of the Safe Haven program
is long-term housing for its residents,
after they leave the program. Although
long-term housing was not a formal indicator
for this project, it is important to
discuss the results in light of this
factor. Taking medications and participating
in programming do not necessarily point
to stability. Similarly, connecting
participants to services is an overall
outcome. The staff participant relationship
is important because connecting participants
to services is a process. A stay at
Safe Haven may not result in a participant
accepting all necessary services. If
trust is built, however, progress can
be made over time, regardless of the
immediate outcome for a person. At the
end of the study period, four people
were still living at Safe Haven. Since
the end of the study period, however,
three of these people have found permanent
housing in apartments, and only one
remains at Safe Haven. Four additional
former residents are permanently housed:
three of these are renting their own
apartments and one person is living
with her family. Two people left the
Safe Haven for long-term hospital care,
and their current housing status is
unknown. One person is now in transitional
housing, and only two former residents
are living on the streets. The housing
status of former residents points to
success with the overall outcome objective
of long-term housing.
CONCLUSION
Safe Haven has a number of overall outcomes
as well as intermediate outcomes. While
persons are residents of Safe Haven
they are encouraged to participate in
services and to take medications. However,
they are not forced to engage in any
services. Building relationships with
staff and others and identifying what
participants feel are their needs are
also actively pursued. A number of stays
at Safe Haven and enrollment in other
programs may be necessary before a person
decides to engage in services. The safe,
low-demand housing provided at Safe
Haven seems to have an effect on people_s
decision to be medicated and to participate
in mental health services. Furthermore,
the supportive environment seems to
contribute positively to the long-term
goal of permanent housing for former
residents.
#2: CONNECTIONS MENTAL HEALTH CASE MANAGEMENT
PROGRAM OBJECTIVE
The purpose of this study was to determine
the effectiveness of this program by
examining its relationship to clients_
maintenance of housing and benefits.
METHODS
Connections is a long-term case management
program for persons with serious mental
illness and a history of homelessness
and uses the Assertive Community Treatment
(ACT) model. The indicators--maintenance
of housing and maintenance of benefits--were
measured over a 6-month period for all
clients in the Connections program as
of January 1997. These clients included
both those in the day program as well
as those receiving only case management.
Clients who enrolled in the program
after January 1997 were not included.
Housing status and benefits received
were measured at Time One in January
1997 and again at Time Two in June 1997.
The program director and a research
assistant collected the data. Most of
the information was reported directly
by the program director; some was obtained
through record review. Clients were
considered successful in maintaining
housing if they were housed in a space
rented to them or provided for them,
and not living in another person_s space
or staying in a shelter. A person who
moved to a new location during the study
period was considered successful in
maintaining housing. Any such movement
was monitored, however, to show stability
in housing and whether or not the move
led to an improved level of functioning
for the person. Connections staff provided
representative payee services, meaning
they received and disbursed benefits
to those clients are entitled to them.
Changes in benefits were monitored and
recorded over the 6-month period. As
of January 1997, there were a total
of 68 Connections clients; 25 were day
program participants, and 43 were nonparticipants.
The same 68 clients were followed over
the 6- month period. In June 1997, there
were 36 day program participants, 27
nonparticipants, and 5 persons who were
no longer clients. Thus, there were
49 clients whose status as a day program
participant/nonparticipant did not change
from Time One to Time Two, and maintenance
of housing and benefits was measured
for these clients. Among these 49 subjects,
23 (47 percent) were participants and
26 (53 percent) were nonparticipants.
Those whose enrollment changed during
the study period and those whose cases
were closed will be described separately.
Participants were categorized into two
groups: light and heavy users of day
program services. Light users attended
the program less than 50 percent of
the days it was open, and heavy users
attended 50 percent or more of the days.
At Time One, 20 of 25 or 80 percent
were heavy users, and only 5 (20 percent)
were light users. At Time Two, of the
36 participants, exactly half (18) were
heavy users and half (18) were light
users. Of the 23 day program participants,
there were 19 (83 percent) men and 4
(17 percent) women. The average age
was 39 years. Racial/ethnic groups included
12 (53 percent) Black, 4 (17 percent)
White, 4 (17 percent) Hispanic, and
3 (13 percent) Asian. The average length
of time as a client in the program was
24 months. Of the 26 nonparticipants,
half were men (13) and half were women
(13); their average age was 49 years.
Racial/ethnic groups included 14 (54
percent) Black, 10 (38 percent) White,
1 (4 percent) Hispanic, and 1 (4 percent)
Asian. The average length of time as
a client in the program was 35 months.
All Connections clients were housed
at Time One. Clients were housed in
either one of the two residential programs
or in single room occupancies and apartments
in the neighborhood. All but one of
the day program participants received
some benefits at Time One. Benefits
received included Medicaid (91 percent),
Supplemental Security Income (SSI) (87
percent), food stamps (57 percent),
restaurant allowance (35 percent), and
Medicare (4 percent). All of the nonparticipants
received benefits at Time One. Benefits
received included SSI (85 percent),
Medicaid (69 percent), food stamps (35
percent), Medicare (23 percent), restaurant
allowance (19 percent), wages from employment
(15 percent), Veterans Benefits (8 percent)
and pension (4 percent).
RESULTS
Among the 23 day program participants,
100 percent maintained housing over
the 6-month period, although, nine (39
percent) of these persons did experience
some change in housing. According to
the program director, four of these
housing changes resulted in a better
level of functioning for the persons;
three changes resulted in a worse level
of functioning; and two changes did
not change the level of functioning.
(More details to be provided in the
Discussion section.) For nonparticipants,
100 percent also maintained housing;
this group, however, experienced no
changes in housing. One hundred percent
of the day program participants maintained
the benefits they were receiving at
Time One. The person who received no
benefits at Time One was receiving SSI,
Medicaid, and food stamps by Time Two.
One person began receiving income from
employment at Time Two, in addition
to maintaining his other benefits. There
were no changes in benefits for nonparticipants;
one hundred percent maintained benefits
over the study period. Fourteen subjects
enrollment in the day program changed
from Time One to Time Two; This group
included eight men, five women, seven
Blacks, five Whites, and one Hispanic.
Their average length of time in the
program was 33 months. Thirteen nonparticipants
at Time One became enrolled in the day
program over the study period. Of the
13, 11 became light users and 2 became
heavy users. One person who had been
a heavy user of 48 the program at Time
One was no longer a day program participant
at Time Two. Among the group of people
whose enrollment status changed, 100
percent maintained housing. There were
two changes in housing, but the move
did not result in a different level
of functioning. Four people experienced
changes in benefits. One change was
positive: a person gained income from
employment. Of the remaining three,
one person lost a restaurant allowance;
one person lost food stamps; and one
person lost all his benefits, including
Medicaid and food stamps. Five people
were no longer Connections clients at
Time Two; these individuals included
two Black women, two Black men, and
one White man. The average length of
time in the program was 25 months. Four
of them were not day program participants
at Time One, and one was a light user.
One of the drop out clients went to
prison; another went to a nursing home
outside the catchment area for the program;
a third client moved across the country;
one client refused services; and one
client could not be located.
DISCUSSION
All subjects maintained housing and
benefits over the study period. Therefore,
subgroup analyses of subject
characteristics to determine success
with the indicators are not useful.
Stability in housing was high in all
groups. Most people maintained the same
dwelling throughout the study. While
some changes in location of housing
did occur, few led to a lower level
of functioning for the person. Level
of functioning was a subjective judgment
made by the program director who had
regular contact with the clients during
the study period. Monitoring improvement
in housing was found to be problematic.
While some housing changes clearly led
to improvements (i.e., cleaner surroundings,
better appliances), other changes such
as increased security, stricter rules
for the tenants, or relocation to a
nursing home could be viewed differently
by different people. It is encouraging
to note that of the clients whose enrollment
status in the day program changed, 13
became day program participants and
only one dropped out of the day program.
Although there was no effect on maintenance
of housing, maintenance of benefits
was not 100 percent for this group.
It is interesting that three people
lost some or all their benefits. Also
of interest is that of the five people
who dropped out of the Connections program
completely, four were not day program
participants at Time One. Therefore,
only 1 day program participant left
the program.
CONCLUSION
All Connections clients were successful
in maintaining housing and benefits
for the 6-month period. Participation
in the day program does not seem to
be the factor responsible for the high
level of success. Case management services,
which are received by all Connections
clients, are more likely responsible
for high levels of maintenance. In order
to show the effects of the day program,
different indicators must be chosen,
keeping in mind the goals and the services
of the day program. For example, if
socialization skills are the desired
outcome, indicators must be designed
to measure progress in this realm.
#3: PRIMARY CARE CLINIC TB PROGRAM
OBJECTIVE
The purpose of this study was to evaluate
the effectiveness of CHO_s primary care
clinic tuberculosis (TB) program through
the measurement of two indicators: completion
of TB prophylaxis and maintenance of
housing for those housed while receiving
directly observed therapy (DOT).
METHODS
Prophylaxis Indicator The CHO measured
the rate of TB prophylactic treatment
completion for persons who had a PPD
positive screening and a subsequent
normal chest x-ray. Records of all persons
screened by CHO, both in the clinic
and in shelters, and all persons referred
for chest x-rays were kept by CHO_s
TB program coordinator.
In 1996, 128 people had chest x-rays
at the Board of Health after being referred
by CHO. The medical chart of every other
person on the list was selected for
review. Only those who started prophylactic
treatment in 1996 were selected as subjects.
This allowed the whole treatment period
to be monitored before the end of the
study period, June 30, 1997, since the
prescribed course of treatment was 6
months in all cases. Charts missing
chest x-ray information and charts for
patients under 18 years of age were
not reviewed. One woman died during
the treatment process and was excluded.
The final number of charts reviewed
was 56; 27 of those actually began the
TB treatment process and were chosen
as subjects. Twenty-nine persons did
not begin treatment. In most cases,
the reason why prophylaxis was not recommended
was not explicitly documented in the
chart. Possible reasons for medication
not having been prescribed include age;
history of alcoholism or liver problems;
and questionable ability to adhere to
treatment. In eight cases, the patient
did not return to the clinic for the
chest x-ray results or did not show
up for an appointment to receive treatment.
Medical records contained information
on the date prophylaxis was prescribed
and progress with treatment. In most
cases, a 1-month supply of medication
was given, and the patient returned
monthly for refills. Provider notes
regarding completion of treatment were
used to determine success. In cases
of non-adherence to treatment, the patient
was considered successful only if he
or she eventually completed the required
course of treatment. Among the 27 randomly
chosen subjects who began TB prophylactic
treatment, there were 19 men and 8 women.
The ethnic/racial breakdown of the group
was 33 percent Black, 30 percent Hispanic,
22 percent White, 7 percent Native American,
and 4 percent Asian. Foreign-born persons
accounted for 11 (41 percent) of the
total and represented the following
countries: Mexico (8), Poland (1), Pakistan
(1), and Albania (1). Ten of these 11
persons had a language other than English
as their primary language. The average
age was 38.7 years. Half had less than
a high school education, 26 percent
had only a high school education, and
19 percent had some college credit or
a degree. Almost three quarters (74
percent) had no medical insurance, while
22 percent had Medicaid benefits, and
4 percent had Medicare benefits. The
average number of clinic visits in 1996
for this group was nine. Almost half
(48 percent) had a history of mental
health problems, and 33 percent had
a history of substance abuse. Housing
Indicator All persons receiving DOT
who were assisted in obtaining housing
by CHO through TB case management from
June 1995 to June 1997 were subjects
for this part of the study. Current
case workers provided lists of these
persons. Clients who were housed but
still receiving TB treatment in June
1997 were not included. In several cases,
clients receiving DOT did not accept
housing assistance from CHO. Some people
paid rent for their own housing, some
lived with friends, and others preferred
to remain in shelters or on the street.
These people were not included as study
subjects, thus the total number of study
subjects was 16. Demographic and treatment
information was obtained from medical
charts. Information about housing status
was obtained through case manager interviews.
Two TB case managers, who had been at
CHO since 1995, were knowledgeable about
the housing status of former clients,
even after case management was terminated.
Among the 16 subjects, there were 14
men and 2 women. There were 12 Blacks,
3 Hispanics, and 1 White person. The
average age was 43 years and the age
range was 35 to 53 years. Five persons
received income through employment during
and after the program, and eight persons
received SSI benefits during and after
the program. One person was in a mental
health program, one person was in a
substance abuse program, and one person
was in a program for persons with HIV.
While receiving DOT, clients were housed
as follows: 14 in single-room occupancy
units, 1 in an apartment, and 1 in a
residential HIV program. All 16 clients
completed TB therapy.
RESULTS
Prophylaxis Indicator Of the 27 people
who began prophylaxis, 12 (44 percent)
successfully completed the treatment,
including 7 men and 5 women. Fifteen
(56 percent) did not successfully complete
the treatment, including 12 men and
3 women. The average number of months
of treatment completed, for those who
did not adhere, was 2.4 months. Among
Black patients, only 10 percent adhered
to treatment while 90 percent did not.
Among Whites, 83 percent adhered while
17 percent did not. Among Hispanics,
75 percent adhered while 25 percent
did not. One Asian and two Native Americans
did not adhere to treatment. The average
age was the same (39 years) for the
group which completed treatment and
the group which did not complete treatment.
A higher percentage of people who had
less than a high school education adhered
(58 percent) than did not adhere (42
percent). Of those who had no medical
insurance, 40 percent adhered and 60
percent did not adhere. Of those who
were Medicaid beneficiaries, 50 percent
complied and 50 percent did not. The
one person with Medicare benefits complied.
Of the 11 foreign-born clients, 8 (73
percent) adhered to treatment and 3
(27 percent) did not adhere to treatment.
The average number of clinic visits
per person in 1996 was slightly higher
for the adherence group (9) than for
the nonadherence group (8). Only 39
percent of persons with a history of
mental health problems adhered, while
61 percent did not adhere. Of persons
with a history of substance abuse, only
22 percent adhered and 78 percent did
not adhere. Housing Indicator Of the
16 subjects, nine (56 percent) were
still housed at the end of the study
period or after 12 months, whichever
came first. Seven (44 percent) did not
maintain housing and were homeless at
the end of the study. Because completion
of DOT occurred on different dates for
individuals, the following categories
were created. Seven clients completed
TB therapy 12 or more months prior to
the end of this study. Of those seven,
four remained housed after 12 months;
one remained housed for 6 months; one
remained housed for 1 month; and one
remained housed for less than 1 month
after completing therapy. One person
who had completed therapy 9 months before
the end of the study was still housed
after 9 months. Of the three people
who completed therapy 6 months prior
to the end of the study, two were still
housed after 6 months, and one did not
maintain housing after completing therapy.
Three months after completing therapy,
two people were still housed, while
two people remained housed for 1 month
and one person did not maintain housing
at all.
DISCUSSION
Prophylaxis Indicator Individuals face
a number of barriers to adherence to
TB prophylaxis. For example, because
persons with TB infection do not have
active disease and may not feel ill,
they may not understand the importance
of completing treatment. Also, the length
of the treatment process may deter some
individuals from completing prophylactic
treatment. This study suggests that
a number of demographic and socioeconomic
characteristics may contribute to adherence
as well. The results suggest that women
are more likely to complete treatment,
while men are more likely not to complete
treatment. The average number of months
of treatment completed, for those who
did not adhere, was 2.4 months. Black
patients appear more likely not to adhere
to treatment than to successfully complete
prophylaxis. Whites and Hispanics are
more likely to complete treatment than
not to complete treatment. There were
no Native Americans or Asians who successfully
completed treatment, however, the number
of people in these groups was too small
to analyze. Age does not seem to be
a factor in adherence to treatment.
It is unknown why people with less than
a high school education are more likely
to adhere than not to adhere. It is
unlikely that lack of insurance contributed
to non-compliance, since the medications
and clinic visits were provided at no
cost to all clients. The reasons for
the high rates of adherence among foreign-born
persons are unknown. Perhaps these persons
were given extra attention by the provider
or translator to make sure they understood
the importance of treatment. Perhaps
these people were more aware of TB treatment
because of high TB prevalence in their
countries of origin. It may also be
possible that if ones immigration status
were an issue, a person would adhere
to medical treatment so as to avoid
contact with the authorities. The average
number of annual clinic visits does
not seem to affect adherence. Persons
with a history of mental health problems
seem to be at risk of non-adherence.
Likewise, persons with a history of
substance abuse are at risk. Because
of the relatively small total number
of subjects and the even smaller number
in specific groups, it is difficult
to determine which factors, if any,
are closely related to treatment adherence/non-adherence.
Overall, the rate of completion of TB
prophylactic therapy was 44 percent.
For CHOs population of homeless clients,
this degree of success was encouraging.
The rate of completion of chemotherapy
for persons with active TB disease in
1996 was 83 percent. Again, the fact
that persons needing prophylaxis do
not have disease symptoms may result
in lower rates of adherence compared
to those who have active TB. As the
results suggest, Black patients and
persons with a history of mental illness
or substance abuse may be at greater
risk for not adhering to treatment.
The CHOs patient population includes
a high proportion of people with these
characteristics. Further evaluation
of CHOs patients who uccessfully/unsuccessfully
complete therapy may be helpful in determining
the reliability and validity of these
findings as well as finding ways to
create messages and programs that are
likely to be successful in targeting
those who are most likely to be at risk
of non-adherence. Housing Indicator
The sample size was small and, therefore,
the analysis of factors related to the
maintenance of housing had limited significance.
Also, there was little variation by
gender, race, or age. The six persons
who did not remain housed or maintained
housing for only 1 month include one
woman and five men, one Hispanic and
five Black clients. Of those who remained
housed after 12 months or by the end
of the study, there were nine men, six
Blacks, two Hispanics, and one White.
These groups are relatively proportional
to the overall group. It is interesting
that the three persons involved in other
programs (mental health, substance abuse,
and HIV) were all housed at the end
of the study. Not surprisingly, the
results suggest that income may be a
factor in maintenance of housing. Of
the nine persons who maintained housing
after completing DOT, seven (78 percent)
received SSI benefits during and after
the program. Of the seven persons who
did not maintain housing, only one (14
percent) received SSI benefits during
and after the program. The influence
of income from employment on maintenance
of housing is not clear. A higher percentage
of employed persons (three out of five)
did not maintain housing, although again,
the total number was very small. Two
of the nine persons who maintained housing
(22 percent) received some income from
employment during and after the program.
Of the seven persons who did not maintain
housing, three (43 percent) earned income
from employment, although they worked
in low-paying and/or part-time jobs.
CONCLUSION
Homeless persons with TB who received
DOT and were housed during treatment
had a 100 percent adherence rate to
treatment. The combination of case management,
including DOT, and provision of housing
are probably dual factors in the success
rate. Over half (56 percent) of the
former clients maintained housing for
up to 1 year after DOT was terminated,
an encouraging number given that they
were homeless before being treated for
TB. Although 44 percent did not maintain
housing, these people successfully completed
TB treatment, and so housing people
while they undergo DOT remains an important
service.
#4: ASTHMA PRIMARY CARE SERVICES
OBJECTIVE
The purpose of this study was to measure
the hospitalization and emergency department
(ED) utilization rates for its adult
asthma patients, in part to determine
the effectiveness of CHOs asthma primary
care services.
METHODS
Using CHO_s management information system,
study coordinators produced a list of
all persons with a diagnosis of asthma
who were treated in 1996, both in the
clinic and at other locations. The chart
of every other person on the list was
reviewed. One of CHOs physicians, a
pulmonologist, reviewed the charts to
confirm that the patients actually were
asthmatic. A total of 51 patients were
identified for the study. Information
on asthma-related hospitalizations and
emergency department utilization in
the 12-month period from August 1996
to September 1997 was obtained retrospectively
by patient report. A data collection
form was attached to the inside of the
subjects charts. Providers were instructed
to ask patients about hospitalizations
and ED visits for asthma in the 12-month
period and to record information including
the hospital name, the date(s), and
the number of days spent at the hospital.
Providers were also asked to rate the
accuracy of the information, based on
their opinion of the patients ability
to self-report. By the end of the project,
only 10 data collection forms had been
completed. Most of the 51 asthma patients
identified for the study did not have
a clinic visit during the time the data
was collected. Because the number of
actual subjects was so small, the data
have limited usefulness, and rates and
subgroup analyses are not significant.
Among the 10 subjects, there were 7
women and 3 men. Three persons were
White, five persons were Black, and
two persons were Hispanic. Their average
age was 39 years. Six persons received
Medicaid benefits, and of those, two
also received Medicare. Four persons
were uninsured.
RESULTS
Of the 10 persons, only 1 had been hospitalized
for asthma during the study period.
This person reported being
hospitalized three times for an average
of 2.7 days each time. Nine persons
reported no asthma-related hospitalizations
during the study period. Only two persons
reported no ED visits during the study
period. Of the eight who did visit an
ED, five made only one visit to the
ED and three made two visits to the
ED. Providers rated the accuracy of
seven of the patients selfreport information.
Four of the providers felt the information
was definitely accurate; three providers
felt the information was probably accurate;
and only one provider felt the information
was probably inaccurate.
Due to the small number of subjects,
it was not possible to determine the
factors related to hospital and ED utilization
by asthma patients. It appears from
this preliminary data that while asthma
patients are not often hospitalized
for asthma, ED visits are common. The
ten subjects charts were reviewed to
monitor use of CHOs primary care clinic.
During the same 12-month period, the
average number of clinic visits for
these subjects was 17.5 (the range was
1 to 37). It is important to note that
many of the people who came frequently
for clinic visits were being treated
for conditions other than asthma (e.g.,
HIV infection, TB infection or disease,
and diabetes). A larger number of subjects
might have shown that those who receive
regular primary care have less asthma-related
crises and utilize the hospital and
the ED less.
CONCLUSION
The methodology of this study failed
mainly because the data collection period
was not long enough to obtain data from
a significant number of patients. In
any case, conclusions would have to
have been made cautiously due to the
potential unreliability of patient self-report
data. Patients may have difficulty recalling
information from the past year. These
indicators might be more feasible if
patients were routinely ask for utilization
information at each visit.