Boston Children’s Hospital Community Asthma Initiative
Roughly 1 in 10 children and 1 in 12 adults have asthma, and about half of the population with asthma will experience an asthma exacerbation or asthma attack each year.1 Advances in safe, effective treatments and well-accepted national guidelines make it possible to control asthma, maintain quality of life, and prevent most hospitalizations and emergency department visits. However, asthma continues to affect children in epidemic proportions, accounting for almost 14 percent of all pediatric hospital admissions in 2010.2 Managing this chronic condition is very costly. In the United States, asthma accounted for an estimated $56 billion in medical costs and lost school and work days in 2007.3
Rates of poorly controlled asthma among low-income children, particularly racial and ethnic minorities, remain disproportionately high. Nationally, low-income children are twice as likely to have asthma than other children, and Black children are 2.5 times more likely than Whites to be hospitalized for asthma.1
About the Boston Children's Hospital Community Asthma Initiative
This disparity is seen in Boston, where rates of pediatric asthma-related hospitalizations across the city are more than 5 times higher for Black and Latino children than for White children.4 The Boston Children's Hospital Community Asthma Initiative (CAI) was developed to address this health disparity and improve the health and quality of life of children with asthma and their families.
Boston Children's CAI selects children for the program based on inpatient admission and emergency department records, and specialty and primary care provider referrals. Children who have been hospitalized or seen in the emergency department are stratified by risk and need for asthma intervention. CAI offers families of at-risk children the opportunity to participate in the program, and the provider explains the program's benefits to the family and develops a personalized asthma management plan.
Program staff work with each family to understand its child's asthma, reviewing the medications used to treat it and identifying asthma triggers in the home and other places where the child spends time. The intervention begins with a home environmental assessment to determine the child's exposures. After the needs of the child have been assessed, CAI staff address some of the underlying causes unique to that family, such as substandard housing or lapses in insurance that can be additional barriers to the family in controlling the child's asthma. Common interventions include providing a vacuum with a High-Efficiency Particulate Arrestance (HEPA) system and bedding encasements for each child. This approach eliminates pests such as mice and cockroaches in a less toxic way than traditional approaches.
The majority of children served by the CAI are low-income Black and/or Latino. CAI was designed to provide culturally and linguistically appropriate asthma education to the family and caregivers of children with asthma. Nurses and community health workers provide case management, tailored to the needs and health literacy of the family, through home visits and telephone followup. This tailored case management ensures that the child's care is coordinated with primary care and asthma specialists. Community health workers receive on-the-job training from CAI staff as well as classroom training through the Massachusetts Department of Public Health to develop the workforce required to effectively care for children with asthma.
An evaluation of the services provided by CAI to 283 children in Boston found significant improvements in the health of children with asthma and reductions in the cost for caring for them. A majority of the participants of ethnic minorities (39.6% Black and 52.3% Latino) were low-income (70.8% had a household income less than $25,000). After 12 months, children served by CAI showed a significant decrease in the number of patients with one or more emergency department visits (68.0%) and hospitalizations (84.8%) due to asthma, days of limited physical activity (42.6%), missed school (41.0%), and parent-missed workdays (49.7%). There was also a significant reduction in hospital costs compared with the comparison community.5 When the study was extended to 3 years of followup, investment in CAI resulted in a social return on investment of 2.56 in 3 years—for every $1 invested in CAI, $2.04 was saved in hospital utilization and $0.52 accrued to the family from fewer missed school days and workdays.6
The program has been supported over time by the Center for Disease Control's Racial and Ethnic Approaches to Community Health (REACH) program, Healthy Tomorrows, Centers for Medicare and Medicaid Services, several foundations, and the hospital's community benefits office. To spread the success of the program and identify barriers to broader implementation, CAI also worked with the American Academy of Pediatrics in Birmingham, Alabama to replicate the model there. The lessons learned and best practices from that effort have been collected into the Boston Children's Hospital Community Asthma Initiative Program Replication Manual. This document has been shared with other organizations seeking to replicate the model in other States, such as Tennessee and Ohio.
Alignment to the National Quality Strategy (NQS):
These efforts promote:
- The most effective prevention and treatment practices for the leading causes of mortality, starting with cardiovascular disease.
The Community Asthma Initiative is run by Boston Children's Hospital. Learn more about the Community Asthma Initiative.
1 Bloom B, Jones LI, Freeman G. Summary health statistics for U.S. children: National Health Interview Survey, 2012. National Center for Health Statistics. Vital Health Stat 10(258). 2013.
2 Lyon M, Markus AR, Rosenbaum S. The Affordable Care Act, medical homes, and childhood asthma: A key opportunity for progress; 2010 [cited 2010 Dec 1]. Available from: www.mcanonline.org/static/images/files_AffordableCareActMedicalHomesAndChildhoodAsthmaBrief.pdf.
3 Barnett SB, Nurmagambetov TA. Costs of Asthma in the Unites States: 2002–2007. Journal of Allergy and Clinical Immunology 2011; 127:145-52.
4 Boston Public Health Commission. Health of Boston 2010 [cited 2010 Dec 10]. Available from: www.bphc.org/hob.
5 Woods ER, Bhaumik U, Sommer SJ, et.al. Community Asthma Initiative: Evaluation of a Quality Improvement Program for Comprehensive Asthma Care. Pediatrics Feb. 2012;129:465-472.
6 Bhaumik U, Walker SP, Sommer SJ, et al. Social Return on Investment from an asthma community-based care management intervention program. American Public Health Association Annual Meeting, Denver, CO, November 8, 2010.