A nurse-led Asthma Care Team transitioning patients from hospital to home improves asthma control: A pilot study exploring an alternative model of care

Lata Jayaram, Andrew Gillman, Sue Casanelia, Valerie Yee, Valerie Hocking, Sanjiwika Wasgewatta, Lynnette Reid-Price, Roslin Botlero, Anne Marie Southcott

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Introduction: Recurrent asthma admissions are frequent in our patients at a tertiary Australian hospital and are commonly related to poor health literacy and medication adherence. A need exists to improve these asthma self-management skills within our current model of care, especially during the vulnerable postdischarge period. Aim: To examine if the addition of a nurse-led Asthma Care Transition Team (ACTT) compared with usual care alone (UC) (1) improves asthma control at 12 weeks posthospital discharge; the number of patients using a Written Action Plan (WAP), compliance with inhaler therapy at 12 weeks, and readmission rates at 6 months. Methods: Adults admitted with asthma were randomised to either: UC: involving review of asthma medication and self-management skills by the ward team prior to discharge; a standard 6-week post discharge clinic visit and a 12-week study visit where an independent assessor assessed outcomes; or ACTT: In addition to UC, involved ACTT nurse-led review at 1 week and 6 weeks. Key aspects included a pre defined, structured review reinforcing education and self-management skills, and telephone support during working hours. Result: Sixty participants (UC and ACTT) had similar baseline characteristics: Mean age: 41 vs 38 years, asthma duration: 20 vs 18 years, baseline Asthma Control Questionnaire 3.1 vs 3.4. At 12 weeks Asthma Control Questionnaire (ACQ) improved significantly in both groups but more so with ACTT; ACTT group had a higher uptake of WAP and a trend to reduced readmissions. Conclusion and Practice Implication: A nurse-led ACTT improves asthma control and self-management skills following discharge and may lead to fewer readmissions.

Original languageEnglish
Number of pages8
JournalHealth Promotion Journal of Australia
Publication statusAccepted/In press - 2022
Externally publishedYes


  • ACQ: Asthma Control Questionnaire
  • action plan
  • asthma
  • asthma self-management skills
  • nurse-led program

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