Every children’s hospital teaches families how to manage asthma before they leave the building. The challenge begins after they get home.
A child returns to a classroom where no one understands the asthma action plan. A caregiver isn’t sure which inhaler is which. A trigger hides in the bedroom. A prescription changes after an emergency department visit, creating confusion about which instructions to follow.
At Children’s Health in Dallas, those realities helped shape an asthma program that now reaches far beyond the hospital walls.
Over the past two years, the program has contributed to a 70% decrease in ED visits and inpatient admissions among participating patients. It also was one of just 11 U.S. organizations to earn the Disease-Specific Care Certification from the Joint Commission.
“We provide services to folks in the community where they’re at,” said Folashade Afolabi, MD, medical director of the Asthma Management Program at Children’s Health and associate professor at UT Southwestern Medical Center. “That makes all the difference.”
How the program works
Families may enter the program after a hospitalization or ED visit. They can also be referred by physicians or enroll themselves. The asthma management team connects with every patient admitted to the hospital for asthma.
Once enrolled, children participate in three- or six-month programs that combine regular telehealth visits, education, care coordination, and home assessments conducted virtually.
Certified asthma educators review asthma action plans, teach inhaler technique, identify barriers to adherence, and help families understand how to manage symptoms before they become emergencies.
“The emphasis is education. It’s so important to have staff who specialize in teaching patients and families,” Afolabi. “At the clinic, they usually only get about half the information they need to really control their asthma.”
Home assessments often reveal obstacles that would never appear in a medical record.
“We found early — before social drivers of health were given a clear name and became well-known — that much of their asthma challenges were really outside the hospital,” Afolabi said.
Children’s Health provides supplies such as allergen-control products and educational materials through philanthropic support. When families face larger environmental challenges, they’re directly connected with community resources.
Asthma educators also provide formal education programs in schools, community recreation centers, and back-to-school events throughout the Dallas area. They train school nurses, work directly with students and families, and partner with school districts seeking asthma support.
A team dedicated to asthma
The program’s frontline workforce looks different from a traditional clinic.
Dedicated respiratory therapists, nurses, social workers, and certified asthma educators provide ongoing support through hospital visits, telehealth appointments, phone calls, school outreach, and community education. Unlike many care models, these team members focus exclusively on asthma management.
“They’re all able to work at the top of their degree without impinging on physician and provider orders,” Afolabi said. “They take ownership of their job and their patient population, which is the only way the program works.”
There’s also a high-risk asthma team with additional staff, including pulmonologists and advanced practice providers.
The benefits of telehealth
One of the program’s most important decisions was expanding its use of telehealth during the COVID-19 pandemic.
Initially, leaders worried the approach would reduce engagement. The opposite happened.
“Telehealth is actually really unique in what we do,” Afolabi said. “We’ve been able to reach more folks.”
Virtual visits allowed the team to serve families across a large geographic region without requiring additional travel or time away from work and school. The format also created opportunities to view home environments and tailor recommendations accordingly.
Children’s Health supplemented those efforts with My Asthma Buddy, an app that provides educational resources, inhaler guidance, symptom tracking, and asthma management tools for families.
How to succeed
Afolabi points to three ingredients behind the program’s 25-year longevity: institutional commitment, dedicated staffing, and experienced educators who are passionate about teaching.
“You need very, very strong institutional support,” she said.
The program has become deeply integrated into the health system’s approach to asthma care. Leadership supports dedicated staffing, while program leaders routinely share outcomes and resource needs with hospital executives.
Just as important is the multidisciplinary team that works with patients every day.
“I am the medical director and sometimes the face of the team,” Afolabi said. “But the RTs, the RNs, the social workers, the disease management folks, and the educators, they’re the heart and soul of the program.”
