What question did this study set out to answer?

The aim is to identify children eligible for intensive asthma management based on their neighborhood conditions and healthcare history.

March 14, 2026

Utilizing Child Opportunity Index to Identify Children Eligible for Asthma Intensive Reinforcement

Key Points

The aim is to identify children eligible for intensive asthma management based on their neighborhood conditions and healthcare history.
Children under 6 years with ≥2 ED visits or ≥1 hospitalization were identified via EMR.
Inclusion criteria were children living in neighborhoods with low COI scores.
The multidisciplinary team reviewed EMR monthly to identify clinical and social barriers to asthma care.
Caregivers were consulted to address identified barriers following clinic visits.
Out of 17 initially identified children, 8 were excluded based on eligibility criteria.
33% of caregivers were difficult to contact; 33% reported social barriers.
66% of children had at least one clinical barrier to care, such as communication issues or access.
22% experienced subsequent hospitalizations or ED visits within 6 months after intervention.

Abstract

Background: Children with ≥2 ED visits or ≥1 hospitalization for asthma are considered high risk. There is a strong link to asthma morbidity, social determinants, and neighborhood conditions. The Child Opportunity Index (COI) is a publicly available resource for measuring neighborhood conditions where higher scores reflect higher opportunity. Children living in neighborhoods with a very low or low score are at higher risk for asthma morbidity and may benefit from care coordination and health navigation to address barriers affecting health outcomes. Methods: Starting July 1, 2023, children ( 6 years of age and/or who were already enrolled in a home visit program, currently being managed within our multidisciplinary asthma clinic, or their primary pulmonary provider requested that they not be included in the AIR pilot were excluded. The multidisciplinary AIR team reviewed the EMR monthly for each child to determine if there were any clinical (communication, refill, access) or social barriers potentially preventing the child from following their asthma action plan. Over a 6-month period an identified team member would call the child’s caregiver to review the AAP, identify and/or address any barriers to care. Identified clinical and/or social barriers and health care utilization was tracked prior and after the start of the AIR pilot. Results: A total of 17 children were initially identified, 8 were excluded. The demographics were median age 4 y, male (78%), English (56%), Black (44%) and Hispanic (56%). There was difficulty contacting 33% of the caregivers. Findings included 33% had social barriers (food, transportation, financial insecurity), 66% had at least one clinical barrier, and 22% had a subsequent hospitalization or ED visit within 6 months. Conclusions: Clinical and social barriers can negatively impact children with asthma being able to follow their asthma action plan. Addressing these barriers after a hospitalization or clinic visit through ongoing care coordination and health navigation can decrease health care utilization. Factors affecting ongoing healthcare utilization may include lack of insurance, beliefs, and ongoing exposure to environmental triggers.Asthma Intensive Reinforcement Pilot Demographicsn=9 Median Age4 yrs (SD 1.13)Gender Male78% (n=7)Female22% (n=2)Language English56% (n=5)Spanish22% (n=2)Other (French, Amharic)22% (n=2)Race Black/African American44% (n=4)White34% (n=3)Other22% (n=2)Ethnicity Hispanic56% (n=5)Not Hispanic44% (n=4)Follow-Up Difficult to contact34% (n=3)Social barriers34% (n=3)Clinical barriers66% (n=6)Healthcare utilization22% (n=2):Local Child Opportunity Index 2.0 Neighborhood Mapping

Mark Helpful

Bookmark

Relay