Boston children's hospital community asthma initiative: QI evaluation of an enhanced care program including workforce development

Objective: The Community Asthma Initiative (CAI) provides case management and home visiting by nurses and community health workers (CHW) for children with poorly controlled asthma.

Methods: Home visits include asthma education, environmental assessment, Integrated Pest Management, and connection to community resources. Data collected over the past 7 years included Emergency Department (ED) visits, hospitalizations; and days of missed school and parent/caregiver work. McNemar's test was used for dichotomous variables, and paired t-tests and General Linear Model repeated measures for continuous variables. Geographic information systems (GIS) data analyzed neighborhood risk factors. Program cost per patient and CAI expansion efforts were tracked.

Results: To date, 986 children were enrolled: 56.0% male; 45.1% Black, 47.3% Hispanic; 72.4% Medicaid; 65.3% household income <$5,000. From parental reports at 12 months compared to baseline, there were significant reductions in patients with any (≥1) hospitalizations (80%), ED visits (56%); and days of missed school (42%) and missed parent/caregiver work (47%) (all p<0.001). GIS mapping showed the majority of patients (65.8%) live in the poorest neighborhoods that are predominantly Black or Hispanic (74%). Home assessments showed that 84.4% had environmental triggers. Total program cost per patient has decreased from $2,600 in FY09 to $2,310 in FY12. A CHW home visiting model with nurse supervision is being tested regionally and nationally with workforce expansion through a local Home Visit Collaborative, regional New England collaborative, and replication in a Southern state.

Conclusion: CAI has improved health outcomes. Expansion of the public health workforce is required for community-based asthma home visiting.