Asthma Care Model Improves the Transition From Hospital to Home

Children hospitalized with asthma often experience delayed follow-up, fragmented care and repeated emergency visits. To address these issues, Cincinnati Children's redesigned the transition from inpatient to outpatient care through a multidisciplinary model spanning 12 divisions and community partners.

The initiative has reduced third-next-available follow-up appointments from 39 days to 6 days while strengthening care coordination for children at highest risk of readmission.

“We’ve realized that reducing asthma readmissions isn’t about a single intervention,” says Theresa Guilbert, MD, MS, director of the Asthma Center. “It requires improving every step of a patient’s transition from the hospital to outpatient care. By bringing together all the people involved with asthma, both in the hospital and community, we’ve been able to coordinate care more effectively and connect families to the support they need.”

Standardized Asthma Care Across Divisions

Because providers across many specialties see asthma patients, the Cincinnati Children’s Asthma Center, in collaboration with the Asthma Learning Health System (ALHS) network, tries to find ways to standardize asthma care as much as possible. Recent efforts have included developing:

• An asthma inpatient medication order set, which guides physicians in Hospital Medicine and Pulmonary Medicine on current international asthma guidelines
• An integrated dashboard for asthma that displays current medications, number of Emergency Department visits and other relevant information to reduce chart prep time
• The Standardization of Asthma Care (SOAC) Committee, with representation from all divisions involved in asthma care at Cincinnati Children’s, to make timely and consistent decisions about treating patients

Sooner Hospital Follow-Up Visits

At Cincinnati Children’s, when a child is hospitalized with asthma, typically, they attend a hospital follow-up visit before returning to their primary care provider or pulmonologist for continued care. But sometimes, scheduling this appointment can take too long.

“We realized there was so much need for asthma care that the time to our third next appointment for asthma and pulmonary was quite lengthy,” explains Guilbert. “So, we are training our advanced practice providers to see hospital follow-ups and some of our new asthma visits.”

Since advanced practice providers have started seeing patients in Asthma Clinics, the current third next available follow-up appointment has decreased from 39 days (June 2025) to 6 days (July 2026).

The goal of this visit is to address any urgent needs a patient has after hospitalization until they can see their regular provider. Patients and families may have a hard time getting prescription refills or have a home environment that worsens their asthma, so timely follow-up visits can help connect them to the appropriate resources.

Better Inpatient to Outpatient Coordination

Two staff positions have dramatically helped transition patients from inpatient to outpatient care—an asthma navigator and asthma coordinator.

The asthma navigator is part of the ALHS network. They screen inpatients and those in the high-risk or Difficult to Treat (DTT) Clinic for social determinants of health. Then, they provide resources from over 35 identified community partners as needed. Examples include transportation assistance to appointments and referrals to the Hamilton County Collaboration to Lessen Environmental Asthma Risks (CLEAR) program, which helps assess and fix rental homes with mold, cockroaches and other asthma triggers.

The asthma coordinator primarily helps educate Pulmonary and Hospital Medicine hospitalized patients. They make sure patients have the correct medications and help them schedule a follow-up appointment before they leave.

Prior to having an asthma coordinator, a median of 56% of patients had a follow-up visit scheduled before leaving the hospital. Now, 76% do.

Specialized Care for High-Risk Asthma Patients

Despite being on high doses of medication, “high-risk” asthma patients often have uncontrolled asthma and are at the greatest risk for hospital readmission. The Asthma Center has prioritized identifying these patients and ensuring they receive the targeted care they need.

At weekly multidisciplinary high-risk patient panels, asthma providers meet to discuss up to eight high-risk patients. They review their charts and determine if they should refer them to the Difficult-to-Treat Asthma Clinic. They also identify interventions that can help prevent the need for future visits.

Additionally, when a high-risk asthma patient comes to the Emergency Department at Cincinnati Children’s, a flag on their chart tells the provider to call Pulmonary Medicine to determine how to treat them, whether to admit the patient or if it’s safe to go home.

Guilbert says because they’re following these kids so closely, they can more easily prevent unnecessary admissions. These patients also receive a follow-up call after an Emergency Department visit to make sure they’re taking the appropriate medications.

“It’s a team effort to understand the complexities of asthma patients,” Guilbert says. “We make sure families leave with the medications they need, understand the care plan, have a timely follow-up appointment, and receive support for challenges that may arise at home.”

The Asthma Center continues to advance pediatric asthma care nationally. Consider referring patients who meet these criteria:

• Frequent hospitalizations
• Recurrent ED visits
• Severe uncontrolled asthma despite recommended therapy
• Difficult social and environmental barriers to care
• Uncertain diagnosis
• Suspected severe asthma that needs multidisciplinary management

(Published August 2026)

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