Change concept
Strengthen GP follow-up after hospital discharge
Most asthma care happens in the community – general practitioners (GPs) play a critical role in long-term management. Ensuring children see their GP within 7 days of discharge helps maintain continuity of care and reduces the risk of re-admission. Evidence shows that timely GP follow-up is linked to better asthma control and fewer hospital visits (Chen et al., 2023).
Change ideas
Work with consumers to create a tailored resource
Co-design a simple guide with families and clinicians that explains:
- what care to expect in hospital
- why GP follow-up matters
- how to prepare for the GP visit.
Provide this resource at discharge and encourage families to take it to their GP appointment.
For example, see the Asthma Australia resource outlining things to ask and tell your doctor.
Ensure families book a GP appointment before leaving hospital
Before families or carers leave the hospital, make sure they have booked a GP appointment.
To support this, ensure that you:
- add GP booking prompts to the discharge checklist
- explain to families and carers why early follow-up is important for asthma management
- support families and carers to make the appointment before they leave, where possible.
Measurement tips
Health services should routinely measure whether children leave hospital with follow‑up care arranged and their GP informed. This includes confirming that:
- a discharge summary is sent to the GP within 48 hours, and
- a GP follow‑up appointment is booked before discharge.
These steps support continuity of care and help reduce the risk of re‑presentation.
How to measure
Measure 1: Discharge summary sent to GP within 48 hours
- Confirm with your local team whether this process is automated and working reliably.
- If automated and reliable, active measurement may not be required.
- If not automated, audit a small sample of recent discharges to check whether summaries were sent within 48 hours.
- As a quality check, consider confirming receipt with a small number of GP practices to ensure the process is working as intended.
Measure details
Numerator: Families whose GP was sent a discharge summary within 48 hours.
Denominator: Families who present to ED or admitted to ward for asthma management.
Measure 2: GP appointment booked before discharge
This information is often not captured in medical records, so an alternative approach may be required.
Options used by participating sites include:
- a short follow‑up survey or prompt to families (with consent) asking whether a GP appointment was booked before discharge and whether it was attended, or
- a brief follow‑up phone call to ask these two questions.
This measure is more resource‑intensive than others. Where possible, consider updating local discharge processes so GP follow‑up booking is documented in the medical record to support future audits.
Measure details
Numerator: Families who had a GP appointment booked before discharge.
Denominator: Families who present to ED or admitted to ward for asthma management.
Lessons from applying MAGIC in practice
Barriers and enablers
Common barriers included:
- families without a regular GP
- difficulties securing timely GP appointments
- families no longer attending GP appointments due to their child's condition improving
- time pressures and competing priorities during discharge that made conversations about follow-up inconsistent
- a lack of feedback on whether GP visits occurred, making it hard to measure impact.
Common enablers included:
- starting the conversation early – at admission, not discharge – helped set expectations
- ensuring families to attend GP appointments even if their child seems healthy and well
- reminders in discharge paperwork and electronic medical record (EMR) prompts improved consistency
- stronger partnerships with GP practices and practice nurses supported continuity
- visual prompts (e.g., MAGIC posters) and consumer-friendly resources reinforced the message
- exploring community programs as alternatives when GP access was limited provided flexibility.
Emphasising to families the importance of a GP follow-up appointment and that any follow-up is important even if it can’t be within a certain timeframe or with normal GP.
Case study: Improving GP integration post-discharge
A paediatric ward in the ICAM collaborative explored ways to improve communication between hospital care and general practice after discharge. The goal was to:
- ensure discharge summaries and care plans reached the child’s GP
- understand whether families attended follow-up appointments within the recommended timeframe.
The ward mapped their discharge process and found gaps in GP follow-up. To address this, they introduced:
- automated discharge summaries sent to GPs via EMR
- printed summaries for families to take to appointments
- education sessions for staff on the importance of GP follow-up.
They found that this approach:
- improved communication between hospital and primary care
- increased awareness among families about the need for timely GP visits.
Lessons learned
- EMR systems automate discharge summary delivery, but do not confirm GP follow-up.
- Having a GP listed in the patient file is essential; clerical staff play a key role.
- There is no current mechanism to track whether families attend GP appointments.
- Follow-up calls may help but require careful planning around timing, staffing, and caregiver burden.
- Integration with My Health Record could offer a future solution for tracking follow-up care.