Integrated Approach to Asthma Care Yields Impressive Outcomes
Asthma is the most common chronic pediatric health condition, but one that can be better controlled through coordinated efforts across a child’s care team.
In a broad-based effort begun in January 2010, pediatricians, hospitalists, nurse practitioners, social workers and school nurses began a chronic care and quality improvement (QI) approach to treating childhood asthma regionally.
The program rolled-out in phases, first targeting inpatient processes for acute asthma management. All patients received a suite of care, including: 30-day supply of all asthma medications in-hand before discharge, inhaler training, administration of Childhood and Asthma Risk-Assessment Tool, consultation by an asthma specialist, and assessment of chronic asthma severity using a standardized care template. In addition, families were referred to a home health pathway consisting of up to five in-home nurse visits for asthma training. Medicaid managed care organizations were provided with discharge summaries.
“One big thing was getting the medicines in the home at the time of discharge,” says Carolyn Kercsmar, MD, director of the Asthma Center at Cincinnati Children’s. A number of barriers exist for families when trying to obtain prescriptions, including lack of a local pharmacy and/or transportation issues. Sending all medications home was vital, as well as the partnership with a local pharmacy to deliver prescriptions with automatic refills. In turn, families learned what constitutes good asthma control: that their kids should be able to go to school, play, and sleep through the night.
In the second phase, care coordination implemented across Cincinnati Children's primary sites, including enhanced pre-visit planning, assessment of barriers to access, adherence and environmental exposures. After December 2010, a web-based registry and alert system was developed to notify managing physicians if patients visited any regional hospital system.
In the third phase, and in partnership with Cincinnati Public Schools, school nurses were trained in Asthma Control Test (ACT) collection, facilitated referrals to asthma subspecialists, completed Cincinnati Children’s QI course, and were given read-only access to Cincinnati Children's EHR system. “Putting more eyes in the sky” to monitor kids, as Kercsmar puts it, helped improve communication with their healthcare provider.
The results of these efforts, published September 2017 in JAMA Pediatrics, are impressive: between January 2010 and June 30, 2014, of the estimated 13,000 Medicaid insured children with asthma in Hamilton County, asthma-related hospitalizations decreased 41.8 percent and ED visits decreased by 42.4 percent. “Since this was a population-based reduction, it was a highly significant accomplishment,” explains Kercsmar.
Ongoing data tracking demonstrates that healthcare utilization rates only continue to improve, thanks to a grand-scale change in how asthma is cared for across the Greater Cincinnati area.