The Utility of Virtual Home Visits to Reduce Asthma Burden in Low-Income Black Communities in Louisiana During the COVID-19 Pandemic

Abstract

Objectives:

The Louisiana Department of Health identified a need for greater outreach in low-income Black communities that addressed environmental asthma triggers. We piloted an asthma virtual home visit (VHV) program and evaluated its reach and ability to promote asthma self-management strategies in communities with a high prevalence of poorly controlled asthma.

Methods:

Participants from Louisiana were continuously recruited into the VHV program starting in March 2021 and provided with asthma education materials. Participants reporting poorly controlled asthma and environmental triggers were also offered 3 VHVs with a respiratory therapist. All participants were asked to complete a preintervention and postintervention knowledge test, an Asthma Control Test (ACT) (maximum score = 25; scores ≤19 indicate poorly controlled asthma), and a final survey that assessed perceptions about asthma management and reduction of environmental triggers.

Results:

As of October 2022, 147 participants were enrolled in the program, and 52 had consented to and received ≥1 VHV. Forty VHV recipients (77%) were aged <18 years, 40 (77%) were Black people, and 46 (88%) were from families with extremely low or low incomes. Asthma symptoms improved across all participants, with a median increase of 2.4 points on the ACT. Knowledge tests revealed that 86% of participants learned about ≥1 new asthma trigger; a larger percentage of VHV recipients than nonrecipients (68% vs 36%) had an improved knowledge test score postintervention. Compared with preintervention, about three-quarters of participants reported feeling more empowered to self-manage their asthma and a significant improvement in their quality of life postintervention.

Conclusions:

The program provided virtual asthma education to communities with a high burden of asthma and improved asthma outcomes for participants. Similar virtual models can be used to promote health equity, especially in areas with limited access to health care.

Asthma is a common chronic disease in the United States that disproportionately affects low-income Black communities and can lead to hospitalization among children and adolescents.^1,2 It can cause lifelong disability and has both genetic and environmental risk factors. ² In addition, environmental triggers in places where people with asthma spend most of their time can exacerbate symptoms that limit meaningful activities and impair quality of life. The US Environmental Protection Agency estimates that people in the United States spend 90% of their time indoors; thus, the place where environmental triggers are most likely to worsen asthma symptoms is in the home. ³ Traditional clinic-based management of asthma that focuses only on appropriate medication use limits the amount of education patients receive about potential environmental triggers.

Many socially vulnerable communities, such as those facing poverty and housing insecurity, face additional risk factors because homes in these communities tend to have high levels of environmental asthma triggers. ⁴ Asthma disproportionately affects children from low-income Black families,^1,2 and low-income families tend to live in homes with worse air quality, poor moisture control, and more allergens and dust than homes occupied by people at higher income levels. ⁴ In addition, renters are more likely than those who own their homes to be exposed to smoke and mold in their homes and are more likely to visit the emergency department or urgent care facilities for asthma symptoms. ⁵ Thus, discussion of clinical management at the physician’s office, while important, may miss important home and lifestyle modifications that can improve symptoms among populations disproportionately affected by asthma.

Home-based interventions that promote clinical and environmental management of asthma have been shown to be beneficial.^6,7 However, in-person home visits can have limitations based on the geographic availability of care providers, especially in rural areas of states such as Louisiana, where health care access is limited. In addition, during the COVID-19 pandemic, in-person home visits posed the risk of disease transmission for patients and health care workers.

Having identified a need to improve asthma outcomes in low-income Black communities on the cusp of the pandemic,^8,9 the Louisiana Department of Health (LDH) attempted to address these issues collectively by piloting the BREATHE (Bringing Respiratory Health Equity for Asthmatics Through Healthier Environments) asthma education program that included a virtual model for asthma home visits. ¹⁰ This virtual home visit (VHV) program was intended to serve Louisiana residents with poorly controlled asthma and substantial home environmental concerns, with a 3-fold objective of improving patients’ asthma control, disseminating knowledge of environmental asthma triggers, and empowering people to self-manage their asthma, such that the impact of asthma on their quality of life would be reduced.

Program Description

The BREATHE pilot program (Figure 1) was designed to bring asthma and healthy homes education to assist with asthma management in areas where the emergency department use for asthma, COVID-19 incidence, Social Vulnerability Index, and environmental health concerns due to outdoor pollutants (eg, particulate matter, ozone) and indoor pollutants (eg, mold) were in the top quartile for the state. ¹⁰ Partnerships with COVID-19 contact tracers, hospital systems, and various community-based organizations allowed us to identify Louisiana residents interested in participating in the program. There was no minimum age requirement to participate, and guardians could opt in on behalf of their children. All interested patients were enrolled via telephone or an online interest form. Interested individuals were screened for enrollment with questions that determined the level of asthma control and exposure to environmental triggers (Table 1), and data were stored in a custom REDCap data management system. Individuals who had a score of ≥2 for asthma severity (maximum score = 6) and a score of ≥2 for environmental triggers (maximum score = 11) were eligible for up to 3 VHVs, 1 month apart. VHVs were conducted on the telehealth platform, ANDOR, by a respiratory therapist (T.M.) at Our Lady of the Lake Children’s Hospital. All enrollees, regardless of VHV eligibility, were provided educational materials via postal mail or email that included information about the clinical and environmental management of asthma. Thus, patients could participate in the BREATHE program in 1 of 2 ways: (1) by only receiving the educational materials via mail or email and (2) by participating in the VHV if they qualified based on the aforementioned criteria. All educational materials can be accessed on the LDH BREATHE website. ¹⁰

Figure 1.

Design of the BREATHE program, Louisiana, 2021-2022. The BREATHE VHV pilot program was designed to bring asthma and healthy homes education to assist with asthma management in areas disproportionately affected by asthma, COVID-19, and social and environmental vulnerability (eg, particulate matter, ozone, indoor mold concerns). Participants not eligible for VHVs get 2 Asthma Control Tests 3 months apart and 1 telephone check-in with LDH at about 3-4 weeks. Abbreviations: BREATHE, Bringing Respiratory Health Equity for Asthmatics Through Healthier Environments; LDH, Louisiana Department of Health; OLOL, Our Lady of the Lake Children’s Hospital; VHV, virtual home visit.

Table 1.

Asthma-related clinical and environmental characteristics of patients in the BREATHE program (n = 147) ^a and demographic characteristics of virtual home visit recipients (n = 52), Louisiana, 2021-2022 ^b

Characteristics	No. (%)
All participants (n = 147)
Clinical
Used rescue inhaler ≥2 times in a typical week	101 (69)
Woke at night ≥2 times in a typical week with asthma symptoms or cough	87 (59)
Filled their rescue medicine ≥2 times in a year	90 (61)
Visited the emergency department ≥2 times and/or were hospitalized ≥1 time in the last 6 months	59 (40)
Had allergies (score = 1)	118 (80)
Home environment
Had moderate or heavy dust build-up in their home	69 (47)
Had seen mold, smelled musty odors, or experienced water leak	40 (27)
Had problems with pests in the last 3 months	44 (30)
Had someone who smoked in the home in the past 7 days	13 (9)
Had gas cooktop	46 (31)
Did not use an exhaust fan or open a window when cooking on the stove	40 (27)
Have furry or feathered pets in the home	60 (41)
Used cleaning agents or perfumed products that have a strong odor	116 (79)
Demographic characteristics of home visit recipients (n = 52)
Age, y
0-17	40 (77)
18-64	11 (21)
≥65	1 (2)
Sex
Female	29 (56)
Male	23 (44)
Race
American Indian/Alaska Native	0
Asian	0
Black	40 (77)
Pacific Islander	0
White	12 (23)
Other	0
Homeownership
Renter	32 (62)
Owns home	20 (38)
Income level, % of annual median income c
<30% (extremely low)	21 (41)
<50% (low)	25 (49)
<80% (moderate)	5 (10)
Parish (county) of residence
East Baton Rouge	23 (44)
Ascension	6 (12)
Iberville	5 (10)
Caddo	4 (8)
Assumption	2 (4)
Jefferson d	2 (4)
Lafayette	2 (4)
West Baton Rouge	2 (4)
Orleans d	1 (2)
Calcasieu	1 (2)
Washington	1 (2)
St. Tammany	1 (2)
Rapides	1 (2)
Ouachita	1 (2)

Abbreviation: BREATHE, Bringing Respiratory Health Equity for Asthmatics Through Healthier Environments.

^aThe BREATHE Virtual Home Visit (VHV) pilot program was designed to bring asthma and healthy homes education to assist with asthma management in areas disproportionately affected by asthma, COVID-19, and social and environmental vulnerability (eg, particulate matter, ozone, indoor mold concerns). ¹⁰

^bDuring prescreening, participants were asked about the clinical features of their asthma and home environment. Patients’ responses were assigned a score (1 = yes, 0 = no), and scores were tallied to determine their eligibility for VHV. Participants who scored ≥2 in the clinical section (maximum score = 6) and ≥2 in the environmental section (maximum score = 11) were eligible to receive up to 3 VHVs by a respiratory therapist.

^cDesignations were based on US Department of Housing and Urban Development designations for a family of 4 (average family size of participants) in the East Baton Rouge metropolitan area (where most participants resided). ¹²

^dJefferson and Orleans parishes together compose the Greater New Orleans area.

The first VHV was focused on building rapport with the patient and discussing asthma management tools, medication adherence, and simple home remedial tips, such as using mattress covers, vacuuming, and using asthma-friendly cleaning agents. The interviewer at this initial visit used an interview form developed by the study team (eFigure 1 in Supplement). The remaining 2 visits were designed to receive updates on patients’ asthma status, discuss takeaway information, and reinforce lessons learned from previous visits. After approximately 3 months, participants were administered a final survey (eFigure 2 in Supplement) that measured their attitudes and perceptions about asthma management and reduction of environmental triggers. Participants were also asked to complete a preintervention and postintervention knowledge test (eFigure 3 in Supplement) and the Asthma Control Test (ACT), a tool previously developed and found to be reliable, valid, and responsive to changes in asthma control (eFigure 4 in Supplement). ¹¹ For children and adolescents aged <18 years, a parent or guardian completed all surveys, except questions on the ACT that required the child to answer them. We then analyzed the data to test the efficacy of the pilot program.

Evaluation Purpose and Criteria

We used a goal-based program evaluation model to assess 4 focus areas, the first evaluating implementation/process and the remaining evaluating effectiveness/outcome. These included (1) populations and areas served, (2) asthma symptom control, (3) knowledge about environmental trigger management, and (4) attitudes and perceptions about asthma self-management and impact of asthma on quality of life. Both groups of participants (VHV recipients and program participants who received educational materials but no VHVs) were compared both within and between groups, whenever possible, to evaluate the success of the VHV program.

We measured populations and areas served by the VHV program by examining the demographic characteristics of VHV recipients. The program aimed to serve patients who were aged <18 years, low income, and Black and who resided in previously identified areas of concern, ⁹ namely East Baton Rouge, Caddo, Jefferson, and Orleans parishes (counties); the latter 2 parishes compose the Greater New Orleans area.

We measured asthma symptom control by comparing preintervention and postintervention ACT scores. The ACT measures the level of asthma control with a maximum score of 25. Scores ≤19 indicate poorly controlled asthma, and scores >19 indicate well-controlled asthma. We defined success as a final ACT score that was higher than the initial ACT score and at least 50% of patients showing improvement. We hypothesized that patients who received VHVs would show better improvement in ACT scores than those who did not.

We measured knowledge about environmental trigger management by comparing preintervention and postintervention knowledge test scores. The knowledge test included 24 questions, with a score of 1 given for each correct answer. We defined success as at least 50% of patients learning about at least 1 environmental trigger and improving their score from preintervention to postintervention. We hypothesized that patients who received VHVs would have better improvement in their knowledge of environmental trigger reduction than those who did not.

We gauged attitudes and perceptions about asthma self-management and impact of asthma on quality of life by using a postintervention survey that asked participants about their perceptions of asthma symptoms, asthma education, environmental trigger reduction, and sense of empowerment related to asthma self-management after participating in the program. We defined success as at least 50% of patients feeling more educated about asthma triggers, feeling more empowered to self-manage their asthma, and having fewer symptoms and environmental triggers postintervention than preintervention. We hypothesized that these factors together would minimize the impact of asthma on patients’ quality of life.

Methods

We evaluated the population served by the VHV program by asking demographic- and housing-related questions during the first VHV. We obtained data on the participants’ age (0-17, 18-64, ≥65 years), sex (female, male), race (American Indian or Alaska Native, Asian, Black, Pacific Islander, White, Other), homeownership status (homeowner, renter), income level (recoded to <30% annual median income [AMI] [extremely low], <50% AMI [low], <80% AMI [moderate]), and parish of residence (by asking for the street address, which was then recoded to parish of residence), among others (eFigure 1 in Supplement). The AMI categories were based on US Department of Housing and Urban Development designations for a family of 4 (average family size of participants) in the East Baton Rouge metropolitan area (where most participants resided). ¹² The LDH Institutional Review Board determined that the project met the criteria for exempt status.

Asthma Symptom Control

We compared patients’ ACT scores from preintervention to postintervention to assess potential improvements in asthma control after participating in the BREATHE program. We summarized initial and final scores (separated by approximately 3 months) for all patients who completed either test (unpaired comparison) and for those who completed both tests (paired comparison) by using the Mann–Whitney U-test. For the 58 patients who completed both the initial and final ACT, we also stratified their scores by the number of VHVs they had received (0, ≥1, or 3) to test whether patients receiving the VHVs experienced greater improvement in asthma control than those who did not receive VHVs. Of note, in all data analyses, the “no VHV” category included patients who did not qualify based on the prescreening criteria and those who qualified but did not consent to receive it. We used nonparametric statistical tests to analyze data with nonnormal distribution, as confirmed using the Shapiro–Wilk and Anderson–Darling tests, with α = .05 considered significant.

Environmental Trigger Education

Along with descriptive statistics, we calculated the percentage of patients who learned about ≥1 new asthma trigger after participating in the program. We determined knowledge gain by tallying the number of patients who answered ≥1 question correctly in the postintervention but not in the preintervention. We also analyzed any increase in the postintervention score (compared with the same person’s preintervention score) to identify the percentage of patients who showed overall greater knowledge of environmental asthma triggers. We then stratified patients who showed improvement by VHV status and compared them using the Fisher exact test to identify the potential impact of VHVs on knowledge gain, with α = .05 considered significant.

Patient Attitudes and Perceptions

We assessed attitudes and perceptions about patients’ ability to self-manage asthma, after participation in the program, through a series of questions. We gauged participants’ sense of empowerment to self-manage asthma after participating in the program based on their response to the question, “After participation in the program, do you feel more empowered to take control of your (or your child’s) asthma?” Answers ranged from 1 (not at all) to 5 (a lot); we considered a score ≥3 to be a positive outcome. We measured perception about potential symptom reduction based on responses to the question, “Since you participated in the program, how often have you (or your child) had asthma symptoms like coughing, wheezing, or needing to use an inhaler?” Response options were more often, less often, about the same, and none at all. Of these, we considered “less often” and “none at all” to be positive outcomes. To understand participants’ beliefs about environmental trigger reduction, we asked a true-or-false question: “Since participating in this program, I believe there are fewer asthma triggers in the home resulting from cleaning practices, pest control practices, smoking, etc.” Separately, we also asked patients about the environmental trigger reduction strategies they implemented. We examined patients’ perceptions about their level of education related to asthma triggers with the question, “How much did you learn about environmental asthma triggers by participating in this program?” Answers ranged from 1 (not at all) to 5 (a lot); we considered a score ≥3 to be a positive outcome. Finally, we asked participants to score the impact that asthma has had on their quality of life during the previous 2 weeks—at enrollment (preintervention) and at the end of the program (postintervention). Responses ranged from 1 (none at all) to 5 (a lot), and a score of ≤3 was considered a positive outcome. We tested the overall shift of percentage of clients experiencing the positive outcome (ie, none, not much, or a little impact) postintervention, as compared with experiencing “quite a bit” or “a lot” preintervention, using the Fisher exact test. We analyzed each question separately for this set of analyses, and the denominator consisted of the total number of patients who responded to the particular question. Stratification by VHV status was not possible for this analysis because of few respondents in the “no VHV” group.

Results

From March 2021 through October 2022, 395 patients were referred to the BREATHE program, of whom 147 (37%) completed the enrollment requirements for the program. Of these, 112 (76%) qualified for the VHV program, of whom 52 (46%) had consented and received ≥1 VHV as of October 2022. Most of the 147 enrollees had allergies (n = 118; 80%) and used a rescue inhaler at least twice in a typical week (n = 101; 69%) (Table 1). The most frequently cited environmental trigger in homes was the use of strongly scented cleaning agents and/or perfumed products (n = 116; 79%). Nearly half (n = 69; 47%) also had moderate or severe dust build-up in their homes. About 61% of enrollees were from the 3 previously identified areas of concern: 25% and 23% were from the East Baton Rouge and Caddo parishes, respectively, and 13% were from the Greater New Orleans area. Most VHV recipients were Black (n = 40; 77%), aged <18 years (n = 40; 77%), renters (n = 32; 62%), and from low-income families (n = 46; 88%). Twenty-three VHV recipients (44%) were from East Baton Rouge Parish.

Asthma Symptom Control

Based on preintervention and postintervention ACT scores, asthma symptoms improved among all enrollees who completed either the initial and/or the final ACT, with a median increase of 2.4 points on the ACT (P = .01; Table 2). Results were similar among the 58 participants who completed both the initial and final ACT, with 62% of patients showing improvement (P = .01). When stratified by VHV status, mean and median ACT scores improved for all groups; however, only the scores of the group of patients who received all 3 VHVs (n = 25) improved significantly (P = .006). Half of patients in both VHV groups started with an ACT score ≤19 and ended with an ACT score >19.

Table 2.

Comparison of preintervention and postintervention Asthma Control Test (ACT) scores ^a of participants in the BREATHE Virtual Home Visit pilot program, Louisiana, 2021-2022 ^b

Characteristics	Preintervention	Postintervention	Change in ACT score c	P value d	No./total (%) of patients whose median score improved
All ACT scores (unpaired)
No. of patients who completed survey	86	62	—	—	—
Mean (SD) score	17.4 (4.8)	19.4 (4.8)	+2.2	—	—
Median score	17.5	20.0	+2.4	.01	—
Paired ACT scores
No. of patients who completed survey	58	58	—	—	—
Mean (SD) score	17.3 (5.0)	19.6 (4.7)	+2.2	—	—
Median score	18.0	20.5	+2.4	.01	36/58 (62)
Median score, by no. of virtual home visits, among patients who completed both ACTs
≥1 Visit	18.0	21.3	+2.0	.05	21/33 (64)
All 3 visits	18.0	21.3	+3.0	.001	19/25 (76)
No visits	15.0	19.0	+4.0	.06	15/25 (60)

Abbreviations: —, does not apply; BREATHE, Bringing Respiratory Health Equity for Asthmatics Through Healthier Environments.

^aThe ACT measures the level of asthma control with a maximum score of 25. Scores ≤19 indicate poorly controlled asthma, and scores >19 indicate well-controlled asthma.

^bThe BREATHE virtual home visit (VHV) pilot program was designed to bring asthma and healthy homes education to assist with asthma management in areas disproportionately affected by asthma, COVID-19, and social and environmental vulnerability (eg, particulate matter, ozone, indoor mold concerns). ¹⁰ Based on the clinical and environmental prescreening information they provided, patients were offered 3 VHVs by a respiratory therapist.

^cThe change in ACT scores was calculated by first taking the difference of each person’s preintervention and postintervention ACT scores and then calculating the average and the median of those values across all participants.

^dDifferences between scores were determined by the Mann–Whitney U test, with P < .05 considered significant.

Knowledge of Environmental Trigger Management

We found no significant difference in median knowledge test scores for the 50 enrollees who completed both the preintervention and postintervention knowledge test (median preintervention test score = 83% vs median postintervention test score = 88%). However, a higher percentage of respondents scored in the 90% to 100% range on the postintervention knowledge test (21 of 50; 42%) than on the preintervention knowledge test (15 of 50; 30%).

When we compared preintervention and postintervention scores, 86% (43 of 50) of all respondents learned about ≥1 new asthma trigger (Figure 2). We found no difference by VHV status; 88% of respondents (22 of 25) who received VHVs learned about ≥1 new environmental trigger compared with 84% of respondents (21 of 25) who did not. Twenty-six of 50 respondents (52%) had a higher test score postintervention than preintervention. We found a significant difference by VHV status (P = .047); 68% of VHV recipients (17 of 25) compared with 36% of non–VHV recipients (9 of 25) had an improved postintervention test score. This finding is consistent with the higher mode observed in the postintervention test scores of VHV recipients (96% postintervention vs 88% preintervention). The mode for the test score in the non–VHV recipient group was 92% for the preintervention and postintervention tests.

Figure 2.

Knowledge gain among BREATHE program participants, stratified by VHV status, Louisiana, 2021-2022. The BREATHE VHV pilot program was designed to bring asthma and healthy homes education to assist with asthma management in areas disproportionately affected by asthma, COVID-19, and social and environmental vulnerability (eg, particulate matter, ozone, indoor mold concerns). All participants were evaluated on their current asthma status and knowledge, attitudes, and perceptions regarding asthma management after participating in the program. Abbreviations: BREATHE, Bringing Respiratory Health Equity for Asthmatics Through Healthier Environments; VHV, virtual home visit.

Attitudes and Perceptions About Asthma Self-management and Impact of Asthma on Quality of Life

Most respondents reported having fewer symptoms (35 of 48; 73%) since participating in the program and feeling more empowered (37 of 49; 76%) and educated (47 of 51; 92%) about self-managing their asthma (Figure 3). Most respondents (37 of 45; 82%) also believed there to be fewer asthma triggers in the home postintervention than preintervention and reported implementing changes such as cleaning more frequently, using asthma-friendly cleaners, avoiding bleach, and ventilating the kitchen when cooking. A significant shift toward reduced impact from asthma on quality of life occurred postintervention. One-third of total respondents (33%; 35 of 106) reported that asthma had “a lot” of impact on their quality of life in the preintervention survey, and 13% of respondents (6 of 47) reported the same in the postintervention survey (Figure 4). Conversely, the percentage of participants who reported no impact of asthma on quality of life rose from 16% (17 of 106) preintervention to 49% (23 of 47) postintervention (P = .002).

Figure 3.

Perceptions about asthma self-management among BREATHE program participants, preintervention and postintervention, Louisiana, 2021-2022. The BREATHE VHV pilot program was designed to bring asthma and healthy homes education to assist with asthma management in areas disproportionately affected by asthma, COVID-19, and social and environmental vulnerability (eg, particulate matter, ozone, indoor mold concerns). Abbreviations: BREATHE, Bringing Respiratory Health Equity for Asthmatics Through Healthier Environments; VHV, virtual home visit.

Figure 4.

Self-reported impact of asthma on quality of life among BREATHE program participants, preintervention and postintervention, Louisiana, 2021-2022. The BREATHE VHV pilot program was designed to bring asthma and healthy homes education to assist with asthma management in areas disproportionately affected by asthma, COVID-19, and social and environmental vulnerability (eg, particulate matter, ozone, indoor mold concerns). Abbreviations: BREATHE, Bringing Respiratory Health Equity for Asthmatics Through Healthier Environments; VHV, virtual home visit.

Lessons Learned

At the start of the COVID-19 pandemic, many in-person public health programs, including several asthma home visiting programs in the United States, attempted to implement virtual models that did not involve in-person contact. While much of the implementation information was shared via websites, presentations, and webinars,^13-15 peer-reviewed literature on the practice and efficacy of these programs is limited. To our knowledge, our study is the first to show improvements in asthma outcomes using a validated measure (ACT scores) among patients who completed the VHV program. Our data also show improvements in patients’ knowledge and perceptions about asthma self-management and a reduced impact of asthma on quality of life among all BREATHE program participants. As such, these data have important public health implications for practitioners, policy makers, and health plans as they consider coverage for virtual visits, especially for Medicaid patients.

The following lessons from the BREATHE VHV pilot program can be useful for public health practitioners:

1. VHVs can provide services to communities that are disproportionately affected by asthma and yield improvements in asthma symptoms (Tables 1 and 2, Figures 3 and 4). Thus, they can be a viable alternative to in-person home visits for asthma and healthy homes education. The virtual model may even be the key to success for people who are uncomfortable with strangers visiting their homes because of privacy, safety, or health concerns.

2. While all patients showed improvement from preintervention to postintervention, those who received VHVs showed greater improvements in knowledge of environmental trigger reduction (Figure 2). This finding suggests that additional time spent discussing the educational material with a trained asthma educator may be helpful for improving knowledge retention.

3. Efforts should be made to complete 3 VHVs because significant improvements in ACT scores were only observed among patients who completed all 3 VHVs (Table 2).

4. Expanding partnerships (especially with clinics and hospitals) to maximize enrollment, providing patients with value-added wraparound services (eg, those that address issues such as housing security, nutrition, employment), allowing patients to access the surveys in multiple ways (telephone, email, and/or text), and incorporating trust-building processes (eg, sharing a photo of the asthma educator ahead of the VHV) can improve participation and retention. Services such as remediation for pests/mold (in coordination with landlords as needed) would also strengthen the program’s impact.

5. A better understanding is needed of the barriers faced by patients who qualified for the VHV program but did not consent to participating. If the barriers are related to technology, then partnering with internet-capable community centers may be helpful.

6. The most common change reported by VHV recipients was a change in cleaning agents. Use of asthma-friendly cleaning agents instead of those that can trigger asthma (eg, bleach) was also the topic that patients showed most improvement on in the knowledge test. If the changes implemented as a result of knowledge gain played a role in improving participants’ symptoms, such low-cost housekeeping modifications could be further promoted by providing patients with green cleaning supplies.^16,17

7. Given the disparities in asthma outcomes faced by low-income Black children, virtual models of asthma education can be a useful tool for reducing disparities and promoting health equity, especially in areas where (and during times when) access to in-person home visits may be limited.

Our study had several limitations. First, the VHV program model was designed based on established best practices,^6,7,15 but it did not take into account any health behavior theory. ¹⁸ Second, the virtual design did not allow for in-person medical and environmental evaluations; as such, professional verification of patients’ self-reported data (eg, pulmonary function tests, home inspections) was not possible. Second, because of the small sample size, we could not evaluate program impact stratified by demographic characteristics such as age or race. Third, the relatively short duration of the pilot program meant that lagging metrics such as changes in emergency and urgent care use could not be evaluated; thus, any cost-saving potential of the program due to reduced health care use could not be presented. Finally, because patients were not required to answer all the questions, we had an uneven number of respondents for the evaluation metrics, which may have skewed the results in some cases. Some of these limitations are being addressed in future iterations of the program, and the results will be described in future publications. Going forward, research should focus on the ability of this program to improve VHV participation and participant retention rates and reduce spending due to unplanned health care use caused by poorly controlled asthma.