The Asthma Follow Up Integrated Care Initiative

Published 28 May 2018. Last updated 12 June 2018.

Sydney Children’s Hospital (SCH) Randwick developed an integrated model of care for children with non-complex asthma, including care coordination, communication with general practitioners (GPs), parent education and emergency department (ED) resources and processes.


To reduce the number of children aged 2-16 with non-complex asthma or viral wheeze, who present to the ED four or more times in a 12-month period, by 50 per cent by December 2017.


  • Improves health outcomes for children with non-complex asthma.
  • Reduces ED presentations of children with non-complex asthma.
  • Improves the healthcare journey for children, parents and carers.
  • Allows children to spend more time at home and less time in hospital.
  • Enhances professional relationships between hospitals and GPs.
  • Improves GP, ED staff and parent education on asthma management.


In 2016, a report by Asthma Queensland and New South Wales stated that repeated asthma-related presentations to EDs are associated with an increased risk of life-threatening asthma. However, Australians are increasingly using hospitals to manage asthma flare-ups that may otherwise have been prevented by engaging with their GP in proactive and planned care.1 Asthma is an ambulatory care sensitive condition, which means hospital may be avoidable with the right primary care.

Prior to the project, anecdotal feedback from care coordinators at Sydney Children’s Hospitals Network (SCHN) showed that parents were anxious about managing their child with asthma or viral wheeze, confused about how to manage the condition and use Asthma Action plans, and had a perception that asthma or viral wheeze was an issue that needs to be managed in an ED rather than by the family GP (despite most children having a GP). When examining the evidence to address this issue, care coordination emerged as an area that has been shown internationally to increase parental confidence, improve asthma and viral wheeze control, reduce school absences, and reduce ED presentations by 36-63 per cent.2,3

It was determined that children who present to the ED four times or more a year with asthma and are then discharged represent a group who does not have optimal support and care in the community. SCH Randwick aimed to develop an integrated model of care to significantly reduce the number of ED re-presentations by this group of children.


  • A new process was developed, where ED staff flag children who are re-presenting to the ED with asthma so they can be reviewed by a care coordinator following discharge.
  • Care coordinators contacted parents of children who re-presented to the ED with asthma by phone and follow-up letter, to facilitate a review with their GP and/or paediatrician. A letter was also sent to the child’s GP.
  • Education sessions were provided for GPs, ED staff and parents of children with asthma. Education was offered in five sessions across two sites and delivered as two hour face-to-face sessions. They combined presentations, hands-on practical elements, interactive discussions and individual guidance to each parent. Resources for home, childcare and school management, as well as contact details for ongoing support and information were also provided.
  • All parents and carers were given a standardised asthma and viral wheeze resource pack on discharge from the ED. This resource pack included their individual Asthma Action Plan, asthma and viral wheeze education, asthma and viral wheeze information pack and discharge instructions (including recommended medical follow-up with a GP).


Sustained – The project has been implemented and is sustained in standard business.


July 2016 – December 2017

Implementation sites

Sydney Children’s Hospital Randwick, SCHN


  • Asthma Australia
  • Central and Eastern Sydney Primary Health Network
  • Clinical Leadership Program
  • University of NSW


The number of children aged 2-16 with non-complex asthma or viral wheeze who presented to the ED four or more times in a 12-month period, reduced by 57 per cent between December 2016 and September 2017.

Between December 2017 and February 2018, 57 children were contacted by Care Coordinators and 87 children with complex asthma were referred to a respiratory clinical nurse coordinator.

Lessons learnt

  • It is important to have a collaborative multidisciplinary team, in order to share expertise, understand all view points and effectively implement change.
  • Try to maintain continuous data monitoring from baseline to final evaluation, to measure the impact of the project.
  • This project was challenging, as there was no control group and asthma presentations are often seasonal.


  1. Asthma Foundation Queensland and New South Wales. Improving Asthma Emergency Department Discharge Processes to Reduce Hospital Readmission Rates. Fortitude Valley, QLD: Asthma Foundation; 2016
  2. Findley S, Rosenthal M, Bryant-Stephens T et al. Community-Based Care Coordination: Practical Applications for Childhood Asthma. Health Promotion Practice 2016;12(6):52S-62S.
  3. Hamburger R, Berhane Z, Gatto M et al. Evaluation of a statewide medical home program on children and young adults with asthma. Journal of Asthma 2015;52(9):940-48.


A/Prof Sue Woolfenden
Clinical Lead Integrated Care
Sydney Children’s Hospitals Network
Phone: 02 9382 8183


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