P3.161: Inpatient Community Health Worker for Asthma Resources and Engagement: The First Six Months

Background: Inner-city asthma disproportionately affects African American children and those living in poverty due to environmental exposures, substandard housing, medication adherence challenges, and inequitable healthcare access. In Detroit, where 83% of residents are African American and 40% live in poverty, asthma disparities are particularly pronounced. Despite various initiatives, asthma morbidity remains high. Addressing social determinants of health (SDOH) is critical to improving asthma outcomes. Community health workers (CHWs) have been successful in outpatient asthma management, but their role in the inpatient setting remains underexplored. Thus, the Inpatient CHW for Asthma Resources and Engagement (I-CARE) program, designed to bridge hospitalization and outpatient follow-up, and address social needs to improve asthma management, began as a pilot in our institution in September 2024.

Methods: This is an ongoing prospective pilot program including children aged 5-17 years with uncontrolled asthma, defined as an Asthma Control Test (ACT) or Childhood-ACT score of < 20 or oral corticosteroid use in the previous year, hospitalized for an acute asthma exacerbation. Baseline data collection and the index visit with the CHW preferentially occurred during hospitalization. The CHW conducted a social needs assessment, provided referrals, and attempted monthly contact with families following hospital discharge. Baseline data included demographics, asthma control (ACT/C-ACT score and activity limitation), social needs using the American Academy of Family Physicians Social Needs Screening Tool, and the number and type of referrals provided by the CHW. Data from the first 6 months of the program (September 2024 – March 2025) are presented.

Results: Of the 72 enrolled patients whose median age was 9 years, 65% (n=67/72) were male, 86% (n=62/72) were African American, and 82% (n=59/72) had state-funded insurance. Asthma control was poor at baseline (median c-ACT: 13.5, ACT: 13.3), and 86% (n=62/72) had activity limitations in the prior 14 days (Table 1). Among social risks, 54% (n=39/72) lived in a home with a household income under $25,000, 69% (n=50/72) in a single-parent home, and more than half faced unmet housing (53%), food (67%), employment (63%), and financial needs (61%). The inpatient CHW met with 79% (n=57/72) of families during hospitalization and provided housing (92%), food (86%), employment (68%), and mental health referrals (35%; Table2).

Conclusion: The majority of enrolled children with uncontrolled asthma in the I-CARE program lived in households facing unmet social needs. Integrating a CHW into inpatient pediatric asthma care is feasible and can effectively identify social risks. This program demonstrates the potential to bridge social gaps in the asthma care of a high-risk, inner-city population. Longitudinal data collection is ongoing and further studies should explore scalability and long-term impacts.