In addition, in Phase II CCs sent text messages to parents/carers reminding them to follow-up with the child's GP. Phase I included a suite of interventions delivered by CCs including encouraging parents/carers to schedule follow-up visits with GP post-discharge, ensuring parents/carers are provided with standard asthma resource pack, offering referrals to asthma education sessions, sending a letter to the child's GP advising of the child's recent hospital presentation and coordinating asthma education webinar for GPs. Children aged 2–16 years who presented ≥4 times to the ED of the SCH,R in the preceding 12 months were enrolled in Phase I and those who had ≥4 ED presentations and ≥1 hospital admissions with asthma attack were enrolled in Phase II. Methods: The integrated model of care was developed by a multidisciplinary team at Sydney Children's Hospital Randwick (SCH,R) and implemented in two phases: Phase I and Phase II. In 2016, The Sydney Children's Hospitals Network launched the Asthma Follow up Integrated Care Initiative with the aim to reduce pediatric asthma emergency department (ED) presentations by 50% through developing and testing an integrated model of care led by care coordinators (CCs). Patient centered care coordination can reduce asthma hospital presentations. Introduction: Frequent asthma attacks in children result in unscheduled hospital presentations.
7General Practitioner, Sydney, NSW, Australia.6Central and Eastern Sydney Public Health Network, Sydney, NSW, Australia.5Rozelle Medical Centre, Sydney, NSW, Australia.4Asthma Australia, Melbourne, VIC, Australia.3Integrated Care, Sydney Children's Hospital Network, Sydney, NSW, Australia.2Sydney Children's Hospital, Sydney, NSW, Australia.1Discipline of Paediatrics and Child Health, Faculty of Medicine and Health, UNSW Sydney, Kensington, NSW, Australia.Nusrat Homaira 1,2 * Emma Dickins 3 Stephanie Hodgson 3 Mei Chan 1 Sandra Wales 2 Melinda Gray 2 Sarah Donnelly 2 Christine Burns 2 Louisa Owens 2 Michael Plaister 2 Anthony Flynn 4 Jennifer Andresen 3 Kimberley Keane 5 Karen Wheeler 6 Bronwyn Gould 7 Nadine Shaw 2 Adam Jaffe 1,2 Christie Breen 3 Lisa Altman 3 Susan Woolfenden 1,3
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