Rationale / Objectives
Asthma is one of the most common chronic diseases in the United States and the leading cause of hospitalization at Boston Children’s Hospital, with most of the admissions coming from five of Boston’s low-income neighbourhoods. Additionally, in Boston, African-American and Latino children are five times more likely to have asthma-related hospitalizations than white children. To help decrease these health disparities, the hospital developed the Community Asthma Initiative (CAI) in 2005 to care for patients along the continuum from individual treatment to policy, by fostering partnerships and utilizing community resources. The initiative provides a comprehensive asthma program to improve access and quality of asthma services for children.
Project/Program Description & Major Achievements
Children are selected to participate in the program based on their medical records, and are arranged by risk and the child’s need for asthma intervention. CAI offers the families of children with asthma the opportunity to participate in the program, and develops a personalized asthma management plan. Additionally, CAI increases the capacity of educational and community organizations to provide asthma education and activities. It also strengthens the existing coalitions that address necessary asthma public health, planning, and policy to make changes in health inequities at systematic levels. Total inpatient admissions and ED visit costs decreased by 61%. One year prior to the intervention the total cost per patient was $2,956; 2 years after intervention the total cost per patient was reduced to $750.
People / Organizations Involved
Boston Children’s Hospital is a tertiary care hospital and the largest provider of pediatric primary care in Massachusetts. The initiative is based on multiple levels needed to reduce health disparities, including the impact of the determinants of health on individuals and families living with asthma. The initiative uses interventions at the individual, family, community and systems levels. To help address the health disparities associated with the asthma rates in Boston; the pilot intervention was focused in four ZIP codes that had the highest asthma rates among African-American and Latino residents. The individual and family level interventions included case management and home visiting services. These services were completed by bicultural, Spanish speaking community health workers to provide culturally sensitive care. The case management services included working with the organizations and individuals necessary to address housing code violations; referrals to inspectional services, legal services, food pantries, and smoking cessation resources; and the assessment of eligibility and assistance for obtaining benefits and services. The home visits included individualized asthma education, and connection to resources; home environment assessments and remediation, education about environmentally friendly cleaning methods; pest management materials; visits by a private pest management company if necessary; and encouragement of smoking cessation. The interventions also included group education, capacity-building in the community and advocacy for broad-based changes in health care delivery for people with asthma. A pilot bundled payment model was also developed for Medicaid/MassHealth for high risk children with asthma and launched in 2012. Further related reading on this kind of approach is available in the article: What is Value-Based Care?
The total inpatient admissions and ED visit costs decreased by 61% as a result of CAI. For CAI patients with 2 years of follow-up the return on investment was 1.46. Specifically, one year before the intervention the total cost per patient was $2,956; 2 years after intervention the total cost per patient was reduced to $750. For 800 children treated through CAI, after 12 months the results are detailed in the table below:
|ED visits||62% decrease|
|Hospital admissions||81% decrease|
|Missed school days||43% decrease|
|Limitation of physical activity||31% decrease|
|Missed work days||47% decrease|