A patient advocate to facilitate access and improve communication, care, and outcomes in adults with moderate or severe asthma: Rationale, design, and methods of a randomized controlled trial.

Few interventions to improve asthma outcomes have targeted low-income minority adults. Even fewer have focused on the real-world practice where care is delivered. We adapted a patient navigator, here called a Patient Advocate (PA), a term preferred by patients, to facilitate and maintain access to chronic care for adults with moderate or severe asthma and prevalent co-morbidities recruited from clinics serving low-income urban neighborhoods. We describe the planning, design, methodology (informed by patient and provider focus groups), baseline results, and challenges of an ongoing randomized controlled trial of 312 adults of a PA intervention implemented in a variety of practices. The PA coaches, models, and assists participants with preparations for a visit with the asthma clinician; attends the visit with permission of participant and provider; and confirms participants' understanding of what transpired at the visit. The PA facilitates scheduling, obtaining insurance coverage, overcoming patients' unique social and administrative barriers to carrying out medical advice and transfer of information between providers and patients. PA activities are individualized, take account of comorbidities, and are generalizable to other chronic diseases. PAs are recent college graduates interested in health-related careers, research experience, working with patients, and generally have the same race/ethnicity distribution as potential participants. We test whether the PA intervention, compared to usual care, is associated with improved and sustained asthma control and other asthma outcomes (prednisone bursts, ED visits, hospitalizations, quality of life, FEV1) relative to baseline. Mediators and moderators of the PA-asthma outcome relationship are examined along with the intervention's cost-effectiveness.

Using IT to improve access, communication, and asthma in African American and Hispanic/Latino Adults: Rationale, design, and methods of a randomized controlled trial.

Asthma morbidity is high among inner-city minority adults. Improving access to care and patient-provider communication are believed to be essential for improving outcomes. Access and communication in turn increasingly rely on information technology including features of the Electronic Health Record. Its patient portal offers web-based communication with providers and practices. How patients with limited resources and educational opportunities can benefit from this portal is unclear. In contrast, home visits by community health workers (CHWs) have improved access to care for asthmatic children and promoted caretaker-clinician communication. We describe the planning, design, and methodology of an ongoing randomized controlled trial for 300 adults, predominantly African American and Hispanic/Latino, with uncontrolled asthma recruited from low income urban neighborhoods who are directed to the most convenient internet access and taught to use the portal, with and without home visits from a CHW. The study 1) compares the effects of the 1-year interventions on asthma outcomes (improved asthma control, quality of life; fewer ED visits and hospitalizations for asthma or any cause), 2) evaluates whether communication (portal use) and access (appointments made/kept) mediate the interventions' effects on asthma outcomes, and 3) investigates effect modification by literacy level, primary language, and convenience of internet access. In home visits, CHWs 1) train patients to competency in portal use, 2) enhance care coordination, 3) communicate the complex social circumstances of patients' lives to providers, and 4) compensate for differences in patients' health literacy skills. The practical challenges to design and implementation in the targeted population are presented.