325 - A Descriptive Study of System and Patient-Level Barriers Identified for High-Risk Pediatric Asthma Patients Through Care Coordination

Publication Number: 2314.325

Mary Kozlowski, University of Cincinnati College of Medicine, Fort Thomas, KY, United States; Elizabeth Avera, Marian University Wood College of Osteopathic Medicine, Indianapolis, IN, United States; Aaron Flicker, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States; Jennifer A. Hall, Cincinnati Children's Hospital Medical Center, Alexandria, KY, United States; Michael Seid, Cincinnati Children's Hospital Medical Center, Cincinnnati, OH, United States; Mfonobong Udoko, Cincinnati Children's Hospital Medical Center, cincinnati, OH, United States

Background: Pediatric asthma places a significant burden on children, their families, and the healthcare system. Attempts to organize treatment efforts via care coordination have been shown to have great potential in improving outcomes for patients but are not yet fully understood.

Objective: A descriptive study of the Asthma Action Huddle (AAH), a model of multidisciplinary care coordination, was performed to 1.) gain a better understanding of the patient population captured by the AAH​ and 2.) describe commonly identified system and patient-level barriers, as well as care coordination outcomes from the AAH.

Design/Methods: The study is a descriptive study using retrospective data collected on high-risk pediatric asthma patients at Cincinnati Children’s Hospital (CCHMC). Patients were selected for inclusion in the AAH by members of the AAH team after a hospital admission for an asthma exacerbation. A total of 220 discussions on 202 unique patients were included, encompassing all patients discussed from July 2024 to July 2025. Patient data from EPIC and the AAH documentation was compiled for each patient. Descriptive statistics were performed on the patient demographic data. Meeting notes for each patient from the AAH were analyzed using standard qualitative data coding methods.

Results: The patient population captured by the AAH during the study period had a mean age of 7.8 years and was 52% male. Health insurance payor was used as a proxy for socioeconomic status: 69% of patients were on public insurance, 27% on private insurance, and 3% self-pay. Patient scores on a standardized social determinants of health screener were also analyzed: 62.1% of patients scored no risk, 21.0% at-risk, and 16.9% with incomplete screeners.
Qualitative data analysis revealed trends in barriers reported by the AAH. Key system-level barriers included discordance with guideline-based therapies, ineligibility for assistance programs, and inadequate processes for determining patient needs and allocating resources.
Key patient-level barriers included low health literacy, financial barriers, and adverse home environments. Analysis of care coordination outcomes identified areas for improvement including modifications to the electronic health record system to mitigate gaps in care, and standardization of AAH procedures, including record keeping and patient follow-up.

Conclusion(s): The patterns of system and patient level barriers suggest common needs amongst high-risk pediatric asthma patients. The identification of these trends offers opportunities for targeted interventions and care-coordination to improve patient outcomes.