Improving Post-Hospital Transitions and Ambulatory Care for Children with Asthma

Asthma is the most common chronic illness in children and their most frequent reason for preventable hospital and emergency department admissions. Children hospitalized for asthma are at increased risk for readmission. There are several reasons for readmission due to asthma, including: 1) hospital provider’s noncompliance with evidence-based asthma preventive measures at patient discharge; 2) poorly managed transitions from hospital care to primary care; 3) failure of primary care providers (PCPs) to monitor and manage chronic asthma; 4) patient noncompliance with asthma home therapy; and 5) failure to establish ongoing monitoring of asthma chronic symptoms. Preventing asthma-related hospitalization and emergency department use can improve quality of life, reduce health care use, and reduce health care costs among children with chronic asthma.

This project worked to develop and implement two health information technology (IT) applications to improve care transitions from the hospital setting to the ambulatory and home settings. The primary objectives of this project were to:

• Develop an asthma-specific Reminder and Decision Support (RADS) system to help hospital providers at discharge: 1) comply with evidence-based asthma preventive measures; determine the patient’s chronic asthma severity level; and determine severity appropriate asthma preventive medications, and 2) establish effective care transitions to PCPs in the ambulatory setting. 
• Develop a Web-based Asthma Home Monitoring System (AHMS -- also called the electronic Asthma Symptom Tracking and Exacerbation Response system, e-ASTER) to: 
• Enable at-home ongoing assessment of patients' level of asthma control and promptly respond to early deteriorations of asthma control, and 
• Support PCPs in monitoring and managing chronic asthma symptoms. 

Secondary objectives included evaluating attitudes, acceptability, use, as well as effectiveness of these IT applications in reducing asthma readmissions.

This project supports effective care transitions and continuity post-hospital discharge, and enhances the quality of ambulatory care for children with asthma to reduce the risk of asthma readmissions. The result of the project serves as a new model for enhancing management of patients with asthma in particular and chronic diseases in general.