Objective

To determine if the Department of Health (Department) effectively identified poor housing conditions for residents with asthma and worked with Local Health Departments (LHDs) to ensure home visits were prioritized. The audit covered the period from April 2014 to January 2021.

About the Program

Asthma is a significant public health problem in the United States. It is one of this country’s most common and costly diseases, which often requires emergency care and hospital admission and is responsible for a high number of missed school and/or work days. According to the Centers for Disease Control and Prevention (CDC), in 2018, asthma accounted for 178,530 hospitalizations and over 1.6 million emergency department visits in the United States. In 2019, asthma accounted for 3,524 deaths. There is no cure for asthma, but it can be managed with treatment and proper prevention of asthma attacks. In New York, it is estimated that 1.4 million adults and 400,000 children have asthma.

The COVID-19 pandemic has had significant impacts on those living with chronic diseases such as asthma. According to the CDC, people with moderate-to-severe or uncontrolled asthma are more likely to be hospitalized from COVID-19. Reducing asthma triggers is one objective of the Department’s Healthy Neighborhoods Program (HNP).

The HNP is designed to provide environmental health services to targeted high-risk neighborhoods. These areas sometimes include environmental justice communities and are usually home to at-risk populations, including low-income and minority families, living in homes and neighborhoods with a disproportionate number of residential hazards. The HNP’s goals include reducing hospitalizations due to asthma and limiting exposure to indoor air pollutants that are known asthma triggers. To accomplish these goals, the HNP contracts with LHDs to perform in-home visits and assessments to raise awareness of and help families manage asthma in order to reduce asthma-related illness and hospitalizations.

During the period from October 31, 2016 through January 19, 2021, LHDs visited 31,302 households, consisting of 77,353 individuals. Of the total households visited, 5,643 (18%) had at least one individual with asthma.

Key Findings

While the Department, through its contracts with LHDs, has identified poor indoor environmental conditions that impact residents with asthma, it needs to improve its oversight and monitoring of LHDs to ensure that individuals identified with asthma in targeted areas continue to receive appropriate assistance.

• LHD-identified target areas are included in Department-approved contracts, but the Department does not assess whether services are provided in those target areas. This lack of oversight by the Department means it cannot properly determine whether LHDs are using HNP funds to raise asthma awareness and help families to manage asthma in areas specifically chosen because of existing environmental and population risk factors. Further, the Department could not provide 39 of the 106 LHD reports required by the terms of the contracts. Progress reports provide accountability and enable project monitoring; therefore, it is uncertain how effectively the Department monitored the program and how the Department determined if LHDs were meeting the goals outlined in their contracts.
• The LHDs did not sufficiently perform the required 1-year follow-up visits to households where at least one individual was identified as having asthma during the initial home visit. However, the Department took no action on the lack of LHD compliance even in the years leading up to the COVID-19 pandemic.
• Separate from the HNP, the Department has a public-facing Asthma Dashboard (Dashboard), which, according to the Department, is updated annually. However, the Dashboard that was publicly available during the course of our fieldwork was significantly outdated – with emergency department visits and hospitalizations displaying information from 2012–2014, deaths displaying information from 2014–2016, and asthma prevalence data as of 2016. The Department indicated that it was unable to update the Dashboard due to the COVID-19 pandemic; however, the majority of the data, such as the asthma indicators, hadn’t been updated in the 4 to 6 years prior to the onset of the pandemic. Without current data, the Department, public health programs, policy makers, and other health care providers cannot adequately recognize the scope of the asthma problem, design and implement solutions, and evaluate impacts in reducing the levels of asthma in the State.
• The Department has not conducted an overall evaluation of the HNP to determine program effectiveness since 2017, nor has it performed any evaluations of LHDs as outlined in the contracts.

Key Recommendations

• Improve oversight of program performance, such as developing policies and procedures, and assess whether LHD services are provided in the target areas identified.
• Collect missing LHD annual reports, cost-benefit analyses, and quarterly reports, where feasible, and ensure all reports are collected going forward.
• Ensure all LHDs are conducting the 1-year asthma follow-up visits and using the required form.
• Update the Asthma Dashboard annually, according to Department policy, and use this data to assess the impact of the HNP on the asthma burden in the State.
• Develop an evaluation to determine the overall effectiveness of the HNP and performance of the LHDs.