Charting a new course in primary care for patients with asthma

Primary care providers at Boston Children’s Primary Care at Longwood have found that their innovative, personalized approach to treating asthma has improved outcomes for children.

Providers recognized that families coping with a child’s asthma needed more guidance than they could get at an annual check-up or sick visit, says Faye Holder-Niles, MD, MPH, a pediatrician and director of the Primary Care Asthma Program.

Knowing that 15 percent of patients in primary care had asthma — and many made frequent trips to the emergency department — Holder-Niles and Linda Haynes, MS, CS, PNP, clinical care manager of the asthma program, decided it was time to rethink how primary care could help.

“We wanted to do more for our patients,” says Haynes. “We felt that we should be partnering with parents to manage their children’s asthma so they would have fewer emergency department visits, and missed school and work days.”

Redesigning primary care

One of the first steps was creating primary care visits specifically for asthma management so providers have time to explain asthma and how to correctly use medications. Providers also teach families to look for early warning signs of an asthma attack, so they can start treatments to prevent severe exacerbations.

“Having a child struggle to breathe is extremely scary, so when families understand how their asthma medications work and how to use them to control symptoms, it’s very empowering,” says Holder-Niles. “It’s life-changing for them to have that level of comfort and understanding.”

As Holder-Niles and Haynes began to work more closely with families, they designed asthma care around their needs. They wanted a comprehensive program that would not only address medical issues, but also assess for unmet social needs that affect a family’s ability to manage asthma. This included asking about inadequate housing, environmental triggers, and transportation challenges, as well as connecting families to social workers and local community organizations for resource support. Through this holistic approach, the asthma program also partnered with Boston Children’s Community Asthma Initiative (CAI) to conduct in-home asthma visits.

CAI provides in-home asthma education, environmental trigger remediation support, and case management for families in Boston. A community health worker supports families and works to decrease the disproportionate high rates of emergency department visits and hospitalizations for low-income families.

“As we learned more from families, our program efforts evolved into an asthma population management strategy where we now provide proactive management, comprehensive care, specialized support and outreach for 2,500 asthma patients,” says Holder-Niles.

Extending the reach

The team also provides education for other health care providers.

“We wanted to be a resource for providers including staff physicians and medical and nursing trainees who care for patient families in our clinic,” says Haynes, adding that they give annual workshops on best practices in asthma management including a review of guidelines by the National Heart, Lung, and Blood Institute.

Additionally, Holder-Niles and Haynes work closely with local community health centers to support and strengthen their asthma work and to help build their asthma population management capacity.  “We share best practices and strategies to proactively reach these patients,” explains Holder-Niles.

They also provide Saturday workshops for providers and staff of community health centers to strengthen their skills. The most recent had more than 40 attendees and covered topics ranging from office emergency triage, asthma medication device techniques, and anaphylaxis.

A framework for change

The asthma program in Primary Care is one of many efforts underway at Boston Children’s to help children with asthma. 

In addition to its partnership with CAI, the asthma program is also linked to the Medical Home Asthma Program (MAP), which is offered to practices in the Pediatric Physician’s Organization at Children’s (PPOC). Holder-Niles and Haynes shared their asthma program model and population management strategies with the PPOC when the organization was in the early stages of planning and implementing MAP.

MAP helps pediatric providers leverage electronic tools to identify at-risk children and connects them to community health workers who can visit patients’ homes to address other issues.

Reducing disparities

“We’re working to not only improve health outcomes, but also to reduce disparities,” says Holder-Niles. “We want to narrow the gap by supporting patients and families in as many ways as possible.”

Since the start of the program, providers have seen fewer urgent care visits, emergency department visits, and inpatient hospitalizations among high-risk children with asthma. This means fewer days missed of school and work for families. Further, children whose asthma is controlled are more likely to be able to play sports, exercise, and maintain a healthy lifestyle, Haynes added.

But there are other important results that aren’t as easily measured.

“Part of our work is really making that deep connection, so a family trusts you and knows that they can talk to you, and share their worries about their child with asthma,” says Holder-Niles.

Learn more about Primary Care at Longwood.