Asthma is a disease that disproportionately affects children from marginalized communities and is a major source of health care costs for our pediatric primary care patients. Children in the communities we serve (such as Mattapan, Roxbury and Dorchester) have rates of emergency department (ED) visits for asthma that are two to three times that of children who live in wealthier communities in Boston. Since 2018, the Pediatric Primary Care Asthma Program has been a multi-faceted practice-wide initiative aimed at transforming care delivery for patients with asthma. We have had ongoing implementation of evidence-based interventions addressing patient, family, home and community level challenges. The goals of our work are to improve outcomes for our approximately 2700 patients with asthma and their families and in doing so, improve quality of life and reduce medical expenses.

Our most comprehensive initiative to date has been the implementation of universal symptom surveillance for every child with asthma at every encounter in primary care—whether that encounter is for a cough, belly pain or an ankle injury. Using a standardized symptom questionnaire, we are able to identify (in seconds) children with suboptimal asthma control. Providers and nurses have a toolbox of interventions at their disposal to address poor asthma control—including patient education, adjustments to the treatment plan and referral to Boston’s Inspectional Services Department—and there is systematic follow up of patients within a few weeks to find out if asthma control has improved.

This has been a major quality improvement project with performance metrics reported to the pediatric primary care team at regular intervals.

A second initiative is the Asthma Intensive Care Management (AIM) Program, started and run by Giovannie Bejin, NP. Using a combination of the asthma registry, ED follow-up requests and referrals from other providers, Bejin has identified a cohort of high-risk children for intensive family-centered outreach, education and frequent follow up. She addresses barriers to optimal home management and optimizes communication between families, school nurses and the child’s medical home. In its first year, 22 of 24 high-ED-utilizing patients did not return to the ED for their asthma.

An essential component to our asthma transformation work has been our partnership with BMC Pharmacy. They assist us in acute asthma care by delivering medications to treat exacerbations at home directly to families while they are in clinic; they have a dedicated queue in the outpatient pharmacy so families with a “Fast Pass” can obtain medications quickly themselves, and they have a robust Home Medication Management/Home Delivery Program in which a pharmacy liaison assures on-time delivery of chronic medications and alerts prescribers to real-time changes with formulary changes so that patients never go without essential medication to control asthma at home.

Other aspects of our initiative include the establishment of a Community Wellness Advocate Home Visiting Program for our highest risk patients, the creation of a clinical algorithm to standardize the management of acute asthma attacks during sick visits to primary care, and the beginnings of a robust and rigorous program evaluation to assess the impact of all of these efforts on our desired outcomes.  All of this work has been carried out by a multidisciplinary team across primary care, pulmonary, pharmacy and IT, including Tami Chase RN, director of Ambulatory Nursing, Giovannie Bejin NP, leader of the AIM program, physician Rachel Sago, MD, nurses Elizabeth Robinson, RN, and Jude Teleau, RN, and Robyn Cohen MD, MPH, pediatric pulmonologist.

Currently, the Center for the Urban Child and Healthy Family is collecting and analyzing data to establish the impact of this initiative on patients in the pediatric practice.