Outcomes from a pilot patient-centered hospital-to-home transition program for children hospitalized with asthma

J Asthma. 2021 Oct;58(10):1384-1394. doi: 10.1080/02770903.2020.1795877. Epub 2020 Aug 4.


Objective: To evaluate a multi-component hospital-to-home (H2H) transition program for children hospitalized with an asthma exacerbation.

Methods: A pilot prospective randomized clinical trial of guideline-based asthma care with and without a patient-centered multi-component H2H program among children enrolled in K-8th grade on Medicaid hospitalized for an asthma exacerbation. H2H program includes 5 components: medications in-hand at discharge, school-based asthma therapy (SBAT) for controller medications, referral for home trigger assessments, communication with the primary care provider (PCP), and patient navigator support. Primary outcomes included feasibility and acceptability. Secondary outcomes included healthcare utilization, asthma morbidity, and caregiver quality of life.

Results: A total of 32 children were enrolled and randomized. Feasibility outcomes in the intervention group included: medications in-hand at discharge (100%); SBAT for controller medication initiated (100%); home visit referrals made (100%) and home visits completed within 4 weeks of discharge (44%); PCP communication (100%); patient navigator communication at 3 days (81.3%) and 14 days (46.7%). Acceptability outcomes in the intervention group included: 87.5% of families continued SBAT, and 87.5% of families reported it was extremely helpful to have the home visit referral. Adjusting for baseline differences in age, asthma severity and control, there was no significant difference in healthcare utilization outcomes.

Conclusion: These pilot data suggest that comprehensive care coordination initiated during the inpatient stay is feasible and acceptable. A larger trial is justified to determine if the intervention may reduce healthcare utilization for urban, minority children with asthma.

Keywords: Asthma; care coordination; home visit; patient navigator; school-based asthma therapy.

Publication types

  • Randomized Controlled Trial
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Anti-Asthmatic Agents / therapeutic use*
  • Asthma / drug therapy
  • Asthma / physiopathology*
  • Caregivers / psychology
  • Child
  • Child, Preschool
  • Communication
  • Continuity of Patient Care / organization & administration*
  • Female
  • Health Services / statistics & numerical data
  • Hospitalization / statistics & numerical data
  • House Calls
  • Humans
  • Male
  • Medicaid
  • Patient Acceptance of Health Care / statistics & numerical data
  • Patient Discharge
  • Patient Navigation / organization & administration
  • Practice Guidelines as Topic
  • Prospective Studies
  • Quality of Life
  • Severity of Illness Index
  • United States


  • Anti-Asthmatic Agents