Predicting and preventing asthma exacerbations in children

Some pediatric primary care providers in Massachusetts have a powerful new way to identify and prevent uncontrolled asthma in children.

The Medical Home Asthma Program (MAP), modeled after the Community Asthma Initiative (CAI), is offered to practices in the Pediatric Physician’s Organization at Children’s (PPOC). MAP helps providers leverage electronic tools to identify at-risk children and provides community health workers who can visit patients’ homes to address the social determinants of health that can aggravate asthma. Social determinants are economic and social factors that affect a person’s health, such as poverty, inadequate housing, or lack of transportation and education.

MAP uses the electronic health record in pediatricians’ offices to look for patients who may need help with their asthma. Additionally, the MAP analytics team mines claims data and examines utilization patterns to try to predict — and prevent — an emergency department visit or hospitalization for asthma. MAP community health workers can access the electronic health record of their patients to review patient records, identify those who might benefit from the program, and communicate directly with primary care offices.

“We wanted an opportunity to prevent that first hospitalization by identifying kids through their primary care provider,” says Dr. Jon Hatoun, medical director of MAP.

To identify higher-risk patients, MAP created a risk score based on the data that looks at prescription filling patterns, the number of outpatient visits for asthma and the occurrence of asthma exacerbations. The MAP team runs a report for each practice monthly to identify patients who may be at increased risk for uncontrolled asthma. They also have a registry of all patients with persistent asthma.

“With a couple of clicks, our providers and community health workers can look for all patients who had an asthma exacerbation in the last seven days,” says Hatoun, who is also associate medical director for Research, Safety, and Quality for the PPOC.

On the MAP

CAI has helped many health care organizations — in Massachusetts and beyond — to create similar asthma programs. MAP is the largest replication effort of CAI so far. It began in 2016, when the CAI team and the PPOC began working together to develop MAP.

“We give full credit to CAI for sharing with us everything from how the community health worker assists families to where and how we document our reports after each visit,” says Hatoun.

CAI received a five-year Healthy Tomorrows grant, from the Health Resources and Services Administration of the U.S. Department of Health and Human Services, to help support the PPOC’s efforts to establish asthma home visiting programs for all its practices outside of the Boston area from 2018 to 2023.

The community health workers who conduct home visits and help families are located right in the pediatrician’s office and often meet with a family after they see their pediatrician. “If they meet a new patient in the pediatrician’s office (rather than through a phone call), there is a better chance of the family enrolling in MAP,” says Hatoun.

More expansions ahead

Since the program began two and a half years ago for South Coast offices, MAP has performed home visits for 340 patients (and enrolled another 30 who have not yet had home visits).

“Our preliminary numbers are showing reduced asthma exacerbations and fewer visits to the hospital,” says Hatoun. “We have also seen that quality of life improves after the intervention.”

The South Coast MAP has been so successful that the program recently expanded into the PPOC’s Western Massachusetts offices, where they have hired two community health workers and have already enrolled 50 patients. Going forward, asthma home visiting programs in the PPOC will be integrated with other supports for practices and families. Regional support teams will not only carry out MAP programming, but they will also be designed to handle more than just asthma.  They will have a case manager and a licensed clinical social worker to help families with behavioral and mental health issues, as well.

Funding for the expansion of MAP and the rollout of regional support teams is possible through a partnership between the PPOC and the Children’s Hospital Integrated Care Organization (CHICO), which oversees the integration of primary care, specialty care and hospital care for Boston Children’s.

Sharing outcomes from Boston

Since 2005, CAI has provided case management to 2,132 patients from Boston Children’s. But the program’s impact extends far beyond Boston.

The CAI team has worked with many different public health groups — from Alabama to Rhode Island — about replicating the CAI or some part of it, says Dr. Elizabeth R. Woods, director of the CAI and associate chief of the Division of Adolescent/Young Adult Medicine at Boston Children’s. CAI staff has provided about 750 trainings and educational talks to more than 20,000 participants.

“It has been a very collaborative effort,” says Woods, who has been involved with the CAI since it began.

A health disparities grant from the Centers for Disease Control and Prevention gave the CAI a greater opportunity to share its outcomes. “The CAI team has always been focused on the bigger picture of how to make programs like the CAI more sustainable,” says Susan Sommer, clinical director of the CAI.

As the focus in health care shifts from a fee-for-service model toward value-based care, there could be increased interest in programs like CAI and MAP that reduce costs by improving care coordination and addressing social determinants of health. New research — using actual claims data — recently published in the Journal of Asthma shows the CAI generates a positive return on investment after two years and actually saves money after three years.

“It’s not only about helping some children in Boston with asthma, but it’s also about creating systemic change where we can really have a broader impact and reach many more children,” says Sommer.

Learn more about the CAI and how to download the Program Replication Manual.