Home Visits for Children With Asthma Reduce Medicaid Costs

Erica T. Marshall, MPH; Jing Guo, PhD; Elizabeth Flood, MPH; Megan T. Sandel, MPH, MD; Matthew D. Sadof, MD; Jean M. Zotter, JD

Disclosures

Prev Chronic Dis. 2020;17(2):e11

Abstract and Introduction

Abstract

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.

Introduction

The effectiveness of home visits by community health workers (CHWs) to children with asthma in improving health outcomes for high-risk populations is established in the literature.^[1] However, that evidence-based model of care has not been widely adopted by health care systems, mainly because of limited coverage by health care payers.^[2] Although many studies have estimated a positive return on investment (ROI) for these home visits, few have used verified cost and use data from participants' medical claims. This absence of data is a barrier to widespread payer reimbursement.^[3–5] Our study, Reducing Ethnic/Racial Asthma Disparities in Youth (READY), used insurance claims data to determine the potential cost savings for Massachusetts Medicaid (MassHealth) of integrating a CHW-led asthma home visiting program into the medical home model of care. The READY study was approved by the Massachusetts Department of Public Health (MDPH) Institutional Review Board (Approval # 00000701).

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Next Section

Table 1. Intervention Timeline, Reducing Ethnic/Racial Asthma Disparities in Youth (READY) Study, 2009–2014
Intervention activity	Visit Number^a
Intervention activity	1	2	3	4	5
Month of visit^b	0	0.5	1	2	6
Activity
General
Project overview	X	X	—	—	—
Set asthma and home priorities and make plan	—	X	—	—	—
Revisit family priorities	—	—	X	X	X
Environmental assessment/education
Home environmental walk-through	—	X	—	—	—
Pest education, develop plan	—	—	X	—	—
Dust mite education, develop plan	—	X	—	—	—
Pets education, develop plan	—	X	—	—	—
Mold education, develop plan	—	X	—	—	—
Dust control education, develop plan	—	—	—	X	—
Tobacco education, develop plan	—	—	X	(X)	—
Reassessment of environmental plans	—	—	X	X	(X)
Social assessment/education
Urgent needs assessment, link with services	X	X	—	—	—
Revisit needs	—	X	(X)	(X)	(X)
Asthma assessment/education
Asthma basics	X	(X)	—	—	—
Asthma management education	—	—	X	X	X
Asthma trigger identification and avoidance	—	X	X	X	—
Asthma care understanding and assessments of barriers to optimal asthma control	X	X	X	X	X

Abbreviation: —, no activity at a visit; X, activity occurred at a visit; (X), activity may have occurred at a visit (at community health worker's discretion).
^aFive visits were made over a 6-month period.
^bRefers to the month of the 6-month study. Some visits were conducted mid month (ie, month 0.5).

Table 2. Evaluation Timeline, Reducing Ethnic/Racial Asthma Disparities in Youth (READY) Study, 2009–2014
Data Collection and Evaluation	Visit Number^a
Data Collection and Evaluation	1	2	3	4	5
Month of Visit^b	0	0.5	1	2	4–6
Consent form (READY and MassHealth permission to share information)	X	—	—	—	—
Home environmental checklist (from Seattle Home Study [7])	—	X	—	—	X
Encounter form (to document CHW actions in home)	X	X	X	X	X
Environmental action plan	—	X	X	X	X
Asthma 2-week recall symptom checklist (from Seattle Home Study [7])	X	X	X	X	X
Baseline survey 1 (asthma data including the Pediatric Asthma Caregiver Quality of Life [14])	X	—	—	—	X
Baseline survey 2 (parental expectations, asthma triggers)	—	X	—	—	X

Table 3. Insurance Claims for Participants (N = 70) Covered by MassHealth (Medicaid) Related to Asthma, Reducing Racial/Ethnic Asthma Disparities in Youth (READY) Study, Massachusetts, 2009–2014
Variable	Control Period^a	Post Period^b	P Value^c
Variable	Mean (Standard Deviation)	Mean (Standard Deviation)	P Value^c
Participants who completed all 5 visits (n = 70)
Average cost per person, $
Hospitalization	1,059.22 (3,199.62)	506.20 (1,948.86)	.11
Emergency department visits	534.73 (809.61)	223.41 (473.77)	.001
Office visits	473.77 (618.94)	406.17 (537.90)	.32
Health care events, no.
Hospitalization	0.21 (0.66)	0.10 (0.39)	.11
Emergency department visits	0.93 (1.15)	0.50 (0.86)	.004
Office visits	3.19 (3.28)	2.96 (3.09)	.69
Participants who completed all 5 visits and had 2 or more emergency department visits during control period (n = 22)
Average cost per person, $
Hospitalization	2,543.76 (4,372.83)	1,243.14 (4,378.39)	.23
Emergency department	1,512.87 (828.25)	454.39 (1,206.34)	.009
Office	730.22 (868.92)	739.91 (773.25)	.52
Health care events, no.
Hospitalization	0.64 (1.09)	0.32 (0.78)	.13
Emergency department visit	2.59 (1.01)	0.95 (2.21)	<.001
Office visit	4.50 (4.61)	4.86 (4.14)	.65