Connecting At-Risk Inpatient Asthmatics to a Community-Based Program to Reduce Home Environmental Risks: Care System Redesign Using Quality Improvement Methods

摘要

Introduction: Connecting patients admitted with asthma to community-based services could improve care and more efficiently allocate resources. We sought to develop and evaluate an intervention to mitigate in-home environmental hazards (eg, pests, mold) for such children.Methods: This was a controlled, quality improvement study on the inpatient units of an urban, academic children’s hospital. Clinicians and public health officials co-developed processes to identify children with in-home risks and refer them for assessment and remediation. Processes assessed were the rate at which those identified as eligible were offered referrals, those referred received inspections, and primary care physicians (PCPs) were notified of risks and referrals. Consecutively occurring and seasonally matched intervention ( n = 30) and historical control ( n = 38) subcohorts were compared with respect to postdischarge mitigating actions (eg, discussions with landlords, PCPs), remaining risks, and morbidity (symptom-free days in previous 2 weeks and Child Asthma Control Test scores).Results: In the first year, the percentage of eligible children offered referrals increased to a sustained rate of ～90%; ～65% of referrals led to in-home inspections ( n = 50); and hazards were abated in 30 homes. PCP notification increased from 50% to ～80%. After discharge, referred parents were more likely to discuss concerns with landlords, the health department, attorneys, and PCPs than patients admitted preimplementation (all P .05). Referred households were more likely to report reduced presence of ≥2 exposures ( P .05). No differences in asthma morbidity were observed.Conclusions: We integrated environmental hazard mitigation into inpatient care. Community-engaged care delivery that reduces risks for poor asthma outcomes can be initiated within the hospital.* Abbreviations: C-ACT : Child Asthma Control Test CCHMC : Cincinnati Children’s Hospital Medical Center CHD : Cincinnati Health Department CLEAR : Collaboration to Lessen Environmental Asthma Risks EHR : electronic health record HCPH : Hamilton County Public Health Department H&P : history and physical PCP : primary care physician QI : quality improvement