Population
Health
All kids have access to primary,
specialty and behavioral health care.
EXEMPLARY PROFESSIONAL PRACTICE
Reducing Asthma Emergencies Through
Coordinated Care
A recent survey showed that El Paso county has the highest
number of young families Colorado. Given national estimates
that 1 in 12 children have asthma, the Breathing Institute
team at our Outpatient Specialty Care location at Briargate in
Colorado Springs is uniquely poised to meet the needs of these
young families, ensuring their optimal lung health. currently followed by an asthma specialist. If they are not, the
family is offered a clinic visit within 30 days of their discharge. At
that outpatient visit, a specialist evaluates their asthma control,
assesses for comorbidities which may impact their control,
makes treatment recommendations and provides extensive
asthma education.
The literature demonstrates that social determinants of health
are major contributors to asthma morbidity and mortality,
and that a follow-up visit after a hospitalization or emergency
department visit decreases returns for emergent asthma care.
Nurses in the Breathing Institute recognized the need to create
the Colorado Springs High-Risk Asthma Program to best serve
their population. In the first eight months of the program, 183 patients were
identified from the Children’s Colorado and University Health
care system in Colorado Springs. Of the identified patients, 42
percent were successfully seen in clinic. Those patients went on
to have fewer ED visits or hospitalizations.
The program seeks to decrease the number of children
who return to the ED or who have repeated asthma-related
hospitalizations, to improve childhood asthma outcomes, to
decrease morbidity and mortality risks, and to decrease the
cost of healthcare by reducing utilization for kids who have
frequent, severe asthma exacerbations.
High-risk asthma patients, as defined by the program, are
between the ages of 2 and 17 and have a primary diagnosis of
asthma with one hospitalization or two or more emergency
room or urgent care visits for asthma in 12 months. They are
identified through weekly reports generated by Children’s
Colorado, University Health-Memorial Hospital and urgent care
sites across the Colorado Springs area.
For the 58 percent who weren’t seen, the primary roadblock was
an inability to contact the family because of incorrect phone
numbers or addresses, or that families did not return calls. In
order for the program to grow, the team determined, an asthma
program coordinator would be critical. The team applied for a
grant through the Medicaid Upper Payment Limit Program that
would fund the position, and the grant was awarded.
The new coordinator will directly oversee the High-Risk Asthma
program, working toward program expansion. That may
potentially lead to inclusion of additional health care systems
in our region, as well as telehealth visits to provide asthma
education for patients and families in rural areas of Southern
Colorado. With this successfully funded grant, the High-
Risk Asthma Program will continue to expand and improve
outcomes for children with asthma and their families.
Once patients are identified, the team works with their primary
care providers and families to ascertain whether they are
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