48 Hour Follow Up Evaluation


To determine what proportion of eligible patients receive follow up; and whether the provision of enhancement funding has had any impact on rates of follow up. 

The program also aims to determine whether: 

  • Socio-demographic, disease and health service factors predict whether someone receives 48 Hour Follow Up; 
  • Compared to Aboriginal people who do not receive 48 Hour Follow Up, whether Aboriginal people who receive follow up have lower rates of 28 day adverse events; 
  • Rates of readmission among Aboriginal people eligible for 48 hour follow up are lower post enhancement funding compared to pre-enhancement funding.


The 48 Hour Follow Up program was conceived as a result of the NSW Walgan Tilly Redesign project, which aimed to address gaps in health care and to improve access for Aboriginal people to chronic care services. The 48 Hour Follow Up program involves following up, within 2 working days of discharge, Aboriginal people aged 15 years and older who are admitted to an acute care facility with a chronic disease.

Follow up is mostly carried out by telephone by a Chronic Care Worker, though home visiting is also an option. 48 Hour Follow Up is currently operational in all Local Health Districts and over 50 facilities in NSW. An early evaluation of the 48 hour follow up model was completed in December 2010.

Preliminary findings suggest that a 48 hour telephone follow up call may assist in reducing readmission rates to 17%. This preliminary evaluation led to the National Partnership Agreement enhancement funding for LHDs to deliver the 48 Hour Follow Up program in May 2012. The NSW Ministry of Health contracted University of Newcastle researchers to conduct an evaluation of the enhancement funding. The evaluation included several components including a literature review and key informant interviews, as well as the examination of data on rates of follow up and readmissions.



The 48 Hour Follow Up program aims to improve the health outcomes of Aboriginal patients with chronic disease, by providing follow up within 2 working days of discharge from hospital. Follow up covers issues such as medications (knowledge of and access to), referrals (booked and transport arranged) and general well-being. This is to ensure appropriate links to GPs, Aboriginal Medical Services, Specialists, or other services to provide care post discharge.

48 Hour Follow Up was developed by the Chronic Care for Aboriginal People team at the ACI, who continue to co-ordinate the implementation and monitoring of 48 Hour Follow Up.

Implementation of 48 Hour Follow Up is undertaken at a local level by Local Health Districts.

The target group is Aboriginal patients admitted to hospital with a chronic disease. Aboriginal patients eligible to be followed up are identified based on a list of ICD-10AM codes for selected chronic diseases (cardiovascular disease, diabetes, chronic renal and respiratory disease) as either their principal or an additional diagnosis.

Rates of unplanned hospital readmissions among Aboriginal people with chronic disease are higher than among non-Aboriginal Australians. The proposed evaluation of the 48 Hour Follow Up program will provide insight into the success of the program in reducing readmissions, and will assist in identifying whether there particular subgroups of people who are less likely to receive follow up. This information will be used to inform future directions for the program.


  • Centre for Aboriginal Health
  • Centre for Epidemiology and Evidence
  • Local Health Districts
  • University of Newcastle

Key Dates

Pilot Sites

Implementation Sites


Component 1: Implementation Review: A review will be undertaken to describe the implementation of 48 Hour Follow Up to date by document review and qualitative staff and stakeholder interviews

Component 2: Monitoring of patient follow up rates: Program monitoring data will be examined to identify the proportion of eligible patients that receive 48hr Follow Up by reviewing LHD submitted reports and HIE reports and the establishment of a register of linked data

Component 3: Impact evaluation:  Hospitalisation data will be examined to assess the impact of 48 Hour Follow Up on hospital readmissions, patient’s eligibility and admitted patient data collection

Component 4: Literature review: A literature review will be undertaken to identify best practices for follow up of Aboriginal patients to prevent readmissions, searching scientific and grey literature.

The 48hr follow up evaluation report 2016 has been released by the Ministry of Health. It can be viewed at www.health.nsw.gov.au/research/Documents/

Related Initiatives

Further Details


Eunice Simons
Aboriginal Chronic Care Project Officer
02 9464 4687

Chris Shipway
Director, Primary Care and Chronic Services
02 9464 4603

Page Top | Added: 7 February 2014 | Last modified: 5 January 2016

Eunice Simons
Aboriginal Chronic Care Project Officer
02 9464 4687