New Coordinated-Care Tools for High-Risk Asthma Patients Improving Health, Costs

Asthma is among the illnesses CHOC is focusing on as a component of its population health initiative. (Other acute care conditions of focus include: bronchiolitis, community acquired pneumonia, acute gastroenteritis, headache and acne.) As a prevalent health care problem in Southern California, asthma results in emergency (ED) visits, hospital admissions, school days missed and administration of complex medications to manage the condition.

In an effort to better coordinate care for these patients, CHOC recently reviewed the data on how frequently children with asthma go to the ED and what their physicians are doing to care for them.  After identifying the care gaps, CHOC provided physicians with clinical care guidelines and tools to help them implement the guidelines. CHOC has also created a patient registry, which helped identify patients who required an asthma action plan. CHOC demonstrated an 18% reduction in ED visits, year-over-year, for patients in their largest primary care practice, CHOC Clinics, which coordinates care for 27,000 of Orange County’s highest risk children.

CHOC Children's

CHOC also identified a subset of its highest-risk Medi-Cal patients with asthma (cohort of 178 children with frequent ED visits, hospitalizations, and/or use of oral steroids) and enrolled them in the CHOC Breathmobile program, a mobile asthma clinic. Over a 15-month period CHOC saw a reduction of:

  • ED visits from 104 to 12
  • Hospital admissions from 13 to 0

As part of CHOC’s comprehensive pediatric system of care, the organization has shifted its approach to become a “promoter of population health,” rather than focusing only on hospital care. To that end, CHOC is outreaching to practicing pediatricians to help them better coordinate care for their patients. The new guidelines and tools to coordinate care for high-risk asthma patients is just one example of how this shift is truly improving children’s health and lowering health care costs.

For more information, please contact Dr. Mike Weiss or Shahab Dadjou, CHOC’s division of population health, at 714-509-9229.