Shannon Thyne
To say that community health care worker Sylvia Raymundo makes house calls to help control childhood asthma is not entirely accurate.
She often visits San Francisco's diverse children in a variety of dwellings - garages, hotel rooms, housing projects and illegal in-law units in neighborhoods including the Tenderloin, Bayview-Hunters Point and the Western Addition.
"Many children live in substandard housing," says Raymundo. "A few are homeless. And sometimes families are overcrowded, with five people living in one hotel room. Many don't qualify for any assistance, but there is no reason why children should not have medicine."
Visiting homes is essential to identify triggers to asthma, whether it's exposure to smoke, dust mites, cat dander, mold, pollens or pollution. Sometimes these visits lead to recommending that the family move to healthier environments.
Affecting nearly 20 million Americans, asthma is a chronic disease of the lungs in which the airways become blocked or narrowed, causing breathing difficulty. Asthma can cause recurrent attacks of symptoms such as wheezing, chest tightness, shortness of breath and coughing. In severe cases, these symptoms can be physically and mentally disabling.
Fortunately, when potential hazards are recognized and removed, asthma can often be prevented or its effects minimized, and patients can have healthy and active lives, says UCSF pediatrician Shannon Thyne, who directs the Pediatric Asthma Clinic at San Francisco General Hospital (SFGH).
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| Sylvia Raymundo, right, educates a mother and son about asthma treaments. |
The Pediatric Asthma Clinic has provided specialty asthma evaluations and follow-up care since 1999. Today, the clinic is staffed by a dedicated team of pediatricians, a psychiatrist serving a fellowship at UCSF, a nurse specializing in asthma who is a graduate of the UCSF School of Nursing and two community health workers who tailor their care and communication to every family.
Community health care worker Raymundo and her counterpart, Stephanie Dunlap, represent the Latino and African American communities, the populations that are disproportionately affected by asthma. Together, children from these two ethnic groups make up more than 75 percent of the patients seen at the clinic. They work to bridge the gap between medical services and social barriers to care by providing culturally and linguistically appropriate education in the clinic and outreach in homes and schools.
Lesson Learned
"I've learned so much about what constitutes cultural competency," Thyne says. "It's good to provide linguistic and cultural expertise, but what it really means is understanding how life experiences affect the health and well-being of families."
Consider the case of one boy. When he first came to the clinic at age 8, he had missed 56 days of school that year. His lung function was normal, but he complained about asthmatic symptoms, Thyne says. After giving him medication and educating him and his mother about treatment and possible triggers, including pets, Raymundo was deployed to visit his home.
"She found a sister sneaking two guinea pigs out the back door," Thyne recalls. "Apparently the sister, who suffered from bipolar disorder, commanded all the family's attention. The mother was depressed."
As soon as the boy began receiving special attention at the asthma clinic, he began to feel better, Thyne says. His sister and mother were referred to mental health services. Today, three years later, the boy's asthma is under control.
Among the myriad lessons learned over the years, Thyne says, is that not all families want or need home visits. Some undocumented Latino families refuse any home visits for fear of being reported to immigration authorities, and others worry about being evicted by landlords. In one case, the remedy was simple - requesting that the landlord remove old carpeting.
In other cases, the solution comes only after practitioners write a letter to the San Francisco Housing Authority to make major improvements or recommend that a family move altogether. So far, the clinic has worked to relocate about 40 families to better housing, thereby improving their lives.
Another lesson is that having a psychologist or psychiatrist on hand at the clinic helps both the child and the family better cope with the chronic disease, or uncovers other problems. Stephen Brockway, a pediatric psychiatry fellow at UCSF, is working a rotation at the Pediatric Asthma Clinic, where he has identified both children and parents who need referrals for more mental health services. In one case, he convened a meeting with a pastor to help the family cope with a severe medical condition.
A National Model
Honored by the American Medical Association and recognized by the Centers for Disease Control (CDC) and Prevention, the clinic exemplifies the efforts of the patient-centered care and communication at SFGH that have become rare in today's managed health care setting.
The clinic's achievements are a community success story. In response to reports of high rates of asthma in Bayview-Hunters Point, Community Health Works of San Francisco initiated the YES WE CAN Children's Asthma Program at SFGH as a medical-social care model for clinic-based, community-focused, team asthma intervention.
YES WE CAN was founded in 1992 by San Francisco State University and City College of San Francisco to address health inequalities by linking academic institutions with communities. Since joining with YES WE CAN, the Pediatric Asthma Clinic at SFGH has served more than 800 patients, with more than 250 receiving home visits and case management. These interventions have demonstrated improvements in provider practices, such as the use of action plans, patient adherence to treatment plans and healthier living conditions.
The approach also has been documented in Managing Children's Asthma: The YES WE CAN Toolkit, which is posted on the CDC website for all to implement. In fact, Associate Chief of Outpatient Clinical Services Cynthia Kim is now trying to replicate the program at UCSF Medical Center. Kim says UCSF has just received funding from the California Department of Health to start the asthma clinic in March.
Thyne, who joined the UCSF faculty at SFGH in 1998, is extremely passionate about and proud of the clinic's work. She even lobbied for continued financial support for the clinic at City Hall. "I found that if I wear my white coat and carry a sign that says 'Children with Asthma Need Your Help,' it can make a difference."
Photos by Elisabeth Fall
Source: Lisa Cisneros
