Medical Student Children's National Health System Washington, District of Columbia, United States
Background: Recurrent hospitalizations and emergency department (ED) utilization for pediatric asthma are a significant health system challenge and reflect long standing social and health inequities. Low rates of routine asthma care and follow-up among patients with frequent ED visits and hospitalizations further exacerbates health disparities and contributes to increased asthma morbidity. Objective: To develop, implement, and evaluate an interdisciplinary care coordination systems’ ability to improve follow up for pediatric patients with asthma at high risk of exacerbation. Design/Methods: Pediatric asthma health care utilization data and supporting metrics were extracted from a novel city wide pediatric asthma registry under a previously created IRB. Four high-risk subgroups were created based on the acuity and frequency of the pediatric asthma visits: 1 PICU admission and less than 5 ED visits; 2+ PICU admissions; 3 Inpatient-non PICU admissions; 5+ ED visits and zero PICU admissions. A standardized social needs screener and conversation template was utilized when contacting families. Interest in a follow up appointment, access to transportation, and additional barriers noted during the conversation were documented and addressed. Appointments with the hospital asthma clinic were scheduled. Visit outcomes were documented as attended, no show, cancel, or rescheduled. Initial scheduling for appointments will be complete by November 30, 2023.
