Home Visits for Children With Asthma Reduce Medicaid Costs.

We conducted a multicomponent, low-cost, home intervention for children with uncontrolled asthma, the Reducing Ethnic/Racial Asthma Disparities in Youth (READY) study, to evaluate its effect on health outcomes and its return on investment. From 2009 through 2014 the study enrolled 289 children aged 2 to 13 years with uncontrolled asthma and their adult caregivers in Boston and Springfield, Massachusetts. Community health workers (CHWs) led in-home asthma management and environmental trigger remediation education over 5 visits spanning 6 months. Asthma health outcomes and indoor environment data were collected via survey, and health use costs were accessed through Massachusetts Medicaid (MassHealth). Results showed significant improvements in asthma control, health care use, and environmental trigger reduction and a positive return on investment (1.34) for participants who had 2 or more emergency department visits 1 year prior to the first home visit. The CHW asthma home visiting intervention improved trigger management, clinical outcomes, and Medicaid cost savings, demonstrating that asthma home visits improve health quality and reduce costs.

Redesigning Health Care Practices to Address Childhood Poverty.

Child poverty in the United States is widespread and has serious negative effects on the health and well-being of children throughout their life course. Child health providers are considering ways to redesign their practices in order to mitigate the negative effects of poverty on children and support the efforts of families to lift themselves out of poverty. To do so, practices need to adopt effective methods to identify poverty-related social determinants of health and provide effective interventions to address them. Identification of needs can be accomplished with a variety of established screening tools. Interventions may include resource directories, best maintained in collaboration with local/regional public health, community, and/or professional organizations; programs embedded in the practice (eg, Reach Out and Read, Healthy Steps for Young Children, Medical-Legal Partnership, Health Leads); and collaboration with home visiting programs. Changes to health care financing are needed to support the delivery of these enhanced services, and active advocacy by child health providers continues to be important in effecting change. We highlight the ongoing work of the Health Care Delivery Subcommittee of the Academic Pediatric Association Task Force on Child Poverty in defining the ways in which child health care practice can be adapted to improve the approach to addressing child poverty.

Determinants of Health and Pediatric Primary Care Practices.

More than 20% of children nationally live in poverty. Pediatric primary care practices are critical points-of-contact for these patients and their families. Practices must consider risks that are rooted in poverty as they determine how to best deliver family-centered care and move toward action on the social determinants of health. The Practice-Level Care Delivery Subgroup of the Academic Pediatric Association's Task Force on Poverty has developed a roadmap for pediatric providers and practices to use as they adopt clinical practice redesign strategies aimed at mitigating poverty's negative impact on child health and well-being. The present article describes how care structures and processes can be altered in ways that align with the needs of families living in poverty. Attention is paid to both facilitators of and barriers to successful redesign strategies. We also illustrate how such a roadmap can be adapted by practices depending on the degree of patient need and the availability of practice resources devoted to intervening on the social determinants of health. In addition, ways in which practices can advocate for families in their communities and nationally are identified. Finally, given the relative dearth of evidence for many poverty-focused interventions in primary care, areas that would benefit from more in-depth study are considered. Such a focus is especially relevant as practices consider how they can best help families mitigate the impact of poverty-related risks in ways that promote long-term health and well-being for children.

Medically Complex Care: The Newest Competency for Primary Care?

CASE: Nola is a complicated 22-month (19-mo corrected) former 34-week premature girl who presents to your practice in the company of her foster caretaker, a maternal aunt. The history you have comes mostly through the lens of her aunt's recall of a variety of clinical encounters and emergency room visits that have taken place at 2 of the region's tertiary care centers, including a prolonged recent hospitalization for failure to thrive. Regrettably, you have no discharge summary on hand from the outside institution.Fortunately, Nola's aunt has come prepared. From her notes, you learn that Nola has a history of feeding difficulties and "global developmental delay." The details of Nola's prenatal and neonatal intensive care unit admission are scant. Nola has been described as having "unusual facial features, such as smallish eyes, low tone, some vision problems." A physical examination demonstrates significant delays in all streams of development. Nola's aunt recalls that she may need a gastrostomy tube pending her weight gain in the next few months.At present, Nola's aunt/foster caretaker is caring for her at home and expresses her concern about 4 major areas: coordinating multiple appointments at various sites, keeping track of involved medical information, getting all of the "paperwork" done to get needed upgrades for a feeding chair, and buying expensive special formula with her own money. Nola's aunt is intelligent and motivated, but she has limited help at home and is overwhelmed with all the aspects of the care. The aunt acknowledges the importance of multiple appointments-feeding support, developmental evaluations, vision, and neurologic assessments. When you inquire who Nola's aunt identifies as her niece's primary care provider, she reports that she has seen different doctors due to the vagaries of her schedule.You conclude that Nola's situation is not likely to improve without a dramatic intervention. As you try to pull together a plan, you wonder what the most effective approach is for the busy clinician. Who should take the lead on a child's care? Can a primary care pediatric clinician partner with other specialists and programs and use other members of a care team effectively? And, does care coordination provide better more cost-effective care?

An analysis of predictors of sustainability efforts at the Inner-City Asthma Intervention sites: after the funding is gone.

BACKGROUND: The Inner-City Asthma Intervention was a national, multicenter implementation of an evidence-based intervention to reduce asthma morbidity in inner-city children that was funded by the Centers for Disease Control and Prevention. Funding was initially planned for 4 years beginning in April 2001, but because of budgetary changes funding ceased in September 2004, 6 months before the original plan. Some sites were able to sustain their asthma program when the funding ended and others were not. OBJECTIVE: To compare characteristics of sites that were able to sustain their asthma program after the original funding ended with those that were not. METHODS: Data were collected from the project manager at each site in an electronic survey and through telephone interview in November 2003 and August 2005. Using contingency tables, we examined the bivariate relationship between each proposed factor and our outcome measure, secured funding. RESULTS: Of the 18 sites that completed the survey, 50% reported continued funding. All sustainable sites received funding from multiple sources, including either the hospital or the community. One site received federal funding and one site received state funding. Of the sites that presented data to multiple funders, 6 of 9 were sustained (P = .05). CONCLUSIONS: Sustainable programs were more likely to be funded locally. Programs that used an evaluative process, including patient outcomes data, to demonstrate the importance of the program to their institution and community were more likely to obtain continued funding compared with those that did not.