For more than ten years, Monica Federico, MD, has been running a high-risk asthma program at Children’s Hospital Colorado.
Her goal is to identify patients who are classified as high risk for future asthma attacks – those who have recently been hospitalized or admitted to the emergency department – and schedule a follow-up visit.
“We know that the patients who are most likely to be hospitalized for asthma are those who have been hospitalized before,” explains Dr. Federico, who is medical director of the asthma program at Children’s Hospital Colorado. “We also know that a follow-up visit significantly decreases the chance that the patient will return to the ED.”
After a decade-long focus on this population, the results speak for themselves: the number of patients seen at the high-risk clinic has increased by 500% to more than 3,000 per year, and the ED return rate for asthma patients is down to 25% from almost 50% five years earlier.
Yet for Dr. Federico and her team, there is more work to be done.
“Asthma is the most common chronic disease of childhood. It has a high morbidity and kids are missing countless days of school. This population is also overwhelmingly Medicaid – 77% – and they often have high social needs. We need to make sure we have the right resources to treat them effectively.”
But finding those resources requires some lateral thinking. To care for children with complex needs, the asthma program developed a multidisciplinary clinic with William Anderson III, MD, and the allergy department to care for children in whom allergies play a role. (Pictured at right: The Children's Hospital Colorado Asthma Team)
Dr. Federico and her team also received a grant from the Department of Public Health and Environment to pilot home visits for asthma patients.
“Health means more than just turning up to the hospital when you’re really sick,” Dr. Federico said. “Medicine and pediatric care is often reactive. But now we can be proactive and go out into the community to make sure the appropriate resources are in place.”
The team for the home visit pilot comprises an asthma nurse, a program coordinator and two community health workers. The latter visit the patient in their home environment to provide education, perform a home assessment, look for asthma triggers and create an access plan and support network for the patient and their family.
“Sometimes patients don’t know where to go for help, so it’s important that we ensure communication is strong,” Dr. Federico said. “This is helped by the fact that our community health workers are from the same communities as many of our patients.”
However, while the teams from the high-risk asthma program and home visit pilot were working hard to build relationships and improve access to care, Dr. Federico realized there was a large hole in her strategy: there was no standardization of care for asthma patients leaving the ED.
“Asthma patients have one of the highest ED return rates, but the ED is a huge department with multiple priorities. The care these patients receive varies by time of day and ED volume, not least by provider, and so there is little standardization to the education, tools, follow up, etc. at discharge.”
In order to standardize care and thus reduce the likelihood of a return visit to the ED, Dr. Federico has been working with Lalit Bajaj, MD, MPH, who is medical director of clinical effectiveness at Children’s Hospital Colorado.
“The clinical effectiveness team (pictured on left) looks at how clinical resources are being used across the hospital and applies evidence-based guidelines and other improvement strategies to optimize them,” Dr. Bajaj explains. “We’ve taken on four main clinical areas: appendicitis, bronchiolitis, asthma and sepsis, but for the asthma program we have been focusing on standardizing and improving the discharge process for inpatient, ED and urgent care for the last four months.”
The discharge standardization project aims to reduce return visits to the ED, and involves multiple physician and inpatient leaders, teams from the ED, respiratory therapists and nurses.
To achieve their goal, the team is developing a checklist for discharge that includes things like the patient’s primary care provider status, current medications, environmental factors such as smoke exposure and an action plan for different levels of asthma severity.
“One of the key things we’re trying to do here is identify barriers and social determinants that impact patient care,” Dr. Bajaj explained. “For many patients there’s a real transportation problem. Are they actually able to get to the clinic? For others it could be financial. Are they able to fill the prescription we give them at the ED?”
“This is about getting a better handle on what resources families need. We don’t have all the answers and can’t solve everyone’s problems, but we can connect patients to our care coordination and case management teams who will try to provide access to the right support.”
Dr. Bajaj explains that it is only by gathering data on such social determinants that the team is able to gauge the extent of factors affecting care and figure out what they can do to mitigate them.
“Even just documenting the number of patients in need will help us to advocate for the right resources,” Dr. Bajaj said. “It’s time to think about novel ways to help our patients. Do we go closer to them? Do we set up a mobile unit? The more you can care for folks in their own communities the better they are, but even simply advocating for access to services will make a difference.”
And making a difference is what both Dr. Federico and Dr. Bajaj are striving toward. In seeking to improve care by addressing health inequalities, the teams involved in the high-risk asthma program, home visit pilot and asthma clinical effectiveness project are making real improvements to patients’ quality of life, something that may set a precedent for other clinical areas across Children’s Colorado.
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