INTEGRATING CARE FOR CHILDREN - Sydney Children's ... · integrating care for children: at a glance The SCHN IC Program achieved outcomes that are directly related to the NSW MoH

I N T E G R AT I N G C A R E

F O R C H I L D R E N

Integrating Care for Children 20182

I N T E G R AT I N G C A R E I N P R AC T I C E : B E N T L E Y ’ S S TO RY 4

I N T R O D U C T I O N 6

I N T E G R AT I N G C A R E I N N S W 8

I N T E G R AT I N G C A R E AT S C H N 10

I N T E G R AT I N G C A R E F O R C H I L D R E N : AT A G L A N C E 12

I N T E G R AT I N G C A R E I S P E R S O N - C E N T R E D A N D TA R G E T E D 14

I N T E G R AT I N G C A R E I S C O L L E C T I V E LY AC C O U N TA B L E 24

C O N N E C T I N G W I T H LO C A L C A R E P R OV I D E R S 24

I N T E G R AT I N G C A R E I S P R I M A RY C A R E B A S E D 3 0

I N T E G R AT I N G C A R E P R O M OT E S C O N T I N U O U S I M P R OV E M E N T 3 6

T H A N K YO U 42

CO N T E N T S

Integrating Care for Children 2018 3

I N T E G R AT I N G C A R E I N P R AC T I C E : B E N T L E Y ’ S S TO RY

Bentley is a cheeky 5-year-old with Nephrotic Syndrome who lives some distance from Sydney Children’s Hospital, Randwick (SCH) and requires albumin infusions three times a week. When first introduced to the Kids GPS Care Coordination Team, Bentley’s mother Jayme was struggling to manage this treatment regimen, with four boys under the age of 8 and no access to a car.


I N T E G R AT E D C A R E I S S E A M L E S S , E F F E C T I V E A N D EFF IC I ENT; I T R EFLEC TS T H E W H O L E O F A P E R S O N ’ S H E A LT H N E E D S , I N PA RT N E R S H I P W I T H T H E I N D I V I D UA L , T H E I R C A R E R S , A N D T H E I R FA M I LY.

The Kids GPS Care Coordinator worked with the Renal team, Jayme, the Clinical Nurse Consultant (CNC), and nurses from Bentley’s local hospital to develop a plan for Bentley’s treatment to be delivered locally. Training on portacaths for the nursing staff at the local hospital was delivered by a SCH CNC, and competency was assessed by the local hospital’s CNC, who delivered similar services to the adult population.

Jayme was introduced to a non government organisation (NGO) which provided transport to the local hospital for treatments. The skill and confidence of the local nursing staff grew quickly with the delivery of regular treatments. Bentley and his family developed a strong relationship with their local hospital, enabling a shared care model that continues to deliver safe, quality care close to home.

Under the SCHN Integrated Care Program, this same model has now been used for children across NSW to tailor care to their needs, both in hospital and at home.


I N T R O D U C T I O N

This report celebrates the achievements of the program for integrating care at the Sydney Children’s Hospitals Network (SCHN IC Program), and outlines further opportunities to work together to support patients, families, carers and healthcare providers.

Increasingly, children and their families manage chronic and complex conditions that would have been life-limiting. These families face significant challenges when navigating the health system, managing their transport needs, meeting costs, and being absent from school and work. To help children with these conditions, services must work together across the continuum of primary, secondary and tertiary care.

The Australian health system is designed for episodic care; it is less equipped to support children and families who are dealing with the medical, emotional and practical impacts of managing a chronic condition. When care is fragmented, the responsibility for coordination and navigation becomes an additional burden for families, resulting in significant psychosocial, educational, employment and financial costs.

Delivering integrated care is one of three key strategic directions in The NSW State Health Plan: Towards 2021.1 Integrated care 2 is seamless, effective and efficient; it reflects the whole of a person’s health needs, in partnership with the individual, their carers, and their family. Integrated care depends on communication and connectivity between providers. It requires a planned system of care that enables individuals to access community-based health and support services close to home.

Integrated care aims to improve:

• the patient experience, and that of their families and carers

• health outcomes• clinician and service provider experience• cost-effectiveness for the healthcare system.

To work towards these aims, the NSW Integrated Care Strategy included measures to support innovators that were undertaking local, discrete integrating care initiatives. Innovator funding associated with the NSW Health Integrated Care Strategy enabled SCHN to better integrate care for children with medical complexities.

Since 2012, SCHN has delivered a number of targeted, integrating care initiatives. This transformational work built on the foundation of cultural change in the health organisation where patient focus and involvement in care decisions is paramount.

The SCHN IC Program was designed, developed and evaluated in partnership with children, families and carers. The program delivers individual care and service outcomes, aiming to:

• reduce preventable hospital admissions • reduce preventable emergency department

(ED) presentations • reduce lengths of stay for children with

medical complexity• improve coordination, streamline care

and optimise use of clinical resources • improve families’ experience and capacity to

manage care for their children • optimise appropriate resources across all

areas to ensure efficiency of care • enhance existing services and develop

evidence-based models of care. 3


“

“

Dealing with the hospital has become too difficult for us to do alone. We’ve spent far too much time there…

but not really achieved very much other than a reduced quality of life for us all, enormous financial stress and lots of absences from school.

Parent, SCHN

The program, delivered since July 2015, has involved more than 1500 children and resulted in:

• improved patient, family and carer experiences• reduced costs to families• 1365 SCHN encounters avoided• 363 inpatient bed days prevented• 487 school absences avoided because care was

provided close to home• over $4.9M cost savings to SCHN• better communication and shared care across care

teams and health sectors• greater satisfaction and confidence among

healthcare providers.

The SCHN IC Program has improved communication, efficiency and effectiveness across the health system. At an individual level, the program coordinates and streamlines care to improve the experiences of patients and their families. The program is designed to be sustainable and it embeds a process for working with local providers to reduce or prevent patients’

needs for ongoing SCHN involvement.

This report highlights the achievements of SCHN’s focus on integrating care (from July 2015 to June 2018) and presents opportunities to sustain and extend the SCHN IC Program. The report outlines how these achievements have been embedded into usual care practices and clinical processes. It demonstrates the program’s value, and highlights a leading example of innovation in integrating care in NSW.


I N T E G R AT I N G C A R E I N N S W

Integrated care is seamless. It is experienced by patients and families as a smooth, continuous process of care that is meaningful and relevant. When care is integrated, patients and their families experience better health outcomes and a more positive experience of care in a system that is simpler to navigate. Integrating care promotes communication across healthcare teams and health sectors while keeping the patient and family at the centre of their care. Where appropriate, care is delivered seamlessly across settings, including close to home and in patients’ local communities.

Integrating care results in benefits for patients, their carers and health professionals:

• making it easier for patients to navigate their way through the health system to the services that are right for them

• improving patient experiences• improving health outcomes• reducing waiting times • delivering care to patients in their local community • reducing the number of hospital admissions, ED

presentations and outpatient clinic attendances• sharing clinical information and care plans

across care teams• Reducing unnecessary duplication of tests

and services.


In NSW, integrating care is based on principles set out by the Ministry of Health (MoH), as presented below.

P E R S O N C E N T R E D• Integrating care works in partnership with consumers.• Patients are at the centre of their own care assessment, planning and delivery. With their families and carers,

patients are actively involved in each step of the care journey, and take part in decisions on how best to meet their needs. They are supported with clear information and timely access to services, from every point of contact.

TA RG E T E D• Service partnerships and coalitions are formed to best support the patient.• Resources are provided where they are most needed. There is equity in access to and delivery of care.

C O L L E C T I V E LY AC C O U N TA B L E• Strong leadership and governance structures support and enhance integrating care.• All service providers and clinicians share responsibility for the patient’s wellbeing. Service providers and clinicians

act with trust and confidence, and there is mutual benefit.

S H A R E D I N F O R M AT I O N• Ensure EMRs indicate that a patient is engaged in Kids GPS Care Coordination or another integrating care initiative.• Share care plans electronically.• Ensure all health professionals involved in the care of a child have access to care plans.• Continue to consult with families on the My Heath Memory app, and develop it to meet their needs. • Improve consistency in the collection and analysis of data, to support ongoing evaluation of integrating care initiatives.

C O N T I N U A L LY I M P ROV E D• A culture of continuous improvement is established across all the services and agencies involved in integrating care.

P R I M A RY C A R E B A S E D• Care is coordinated through the primary healthcare providers that are most appropriate to the person’s needs.• There is a focus on building capacity in the primary care sector.


I N T E G R AT I N G C A R E AT S C H N

SCHN’s investment in, and commitment to integrating care is continuing and future priorities for its sustainability are presented in this report’s final section.

SCHN comprises:

• The Children’s Hospital at Westmead (CHW) and Sydney Children’s Hospital, Randwick (SCH)

– the two major tertiary and quaternary children’s hospitals in metropolitan Sydney

• Bear Cottage, a specialist hospice for children with life-limiting conditions

• NSW Newborn and paediatric Emergency Transport Service

• NSW Pregnancy and Newborn Services Network • Children’s Court Clinic.

C H A L L E N G E

SCHN acknowledges that children with medical complexity require care from large multidisciplinary teams of specialist doctors, nurses and allied health professionals. This makes these children particularly vulnerable to the health system’s fragmentation, and they can become dependent on SCHN and disengaged from local services.

M E E T I N G T H E C H A L L E N G E

The SCHN IC Program supports families who are caring for children with medical complexity. The program works with families to develop shared care models and bring together the entire continuum of services (primary, secondary and tertiary). Within the integrating care model, the Kids Guided Personalised Services (GPS) Care Coordination Service supports families to navigate the health system and works with families to create shared care plans.

P RO G R A M

The SCHN IC Program supports the NSW MoH principles for integrating care. It is person-centred, targeted, continually improved, based on information sharing, primary care based, and collectively accountable.

The program focuses on achieving comprehensive system transformation. The SCHN IC Program team works in partnership with children, families and carers, local health districts (LHDs), primary health networks (PHNs), consumer support organisations, general practitioners (GPs) and community services.Service partners collaborated on a number of initiatives, testing models for integrating care, and designing key integrating care enablers to help families feel safe wherever they access care in the health system.

Evaluation of the Integrated Care program involved consulting with parents and healthcare providers, and medical and quality improvement teams. The data collated from that evaluation has helped inform program design and improvements.


AC H I E V E M E N T S

SCHN is one of the leaders in integrating care across NSW, performing significantly above the state average in the following areas:

• delivering patient-centred care and enabling empowerment

• sharing information and improving services, via digital health and analytics

• primary care-centred models of care• continuous improvement, program

and service innovation.


I N T E G R AT I N G C A R E F O R C H I L D R E N : AT A G L A N C E

The SCHN IC Program achieved outcomes that are directly related to the NSW MoH Strategic Framework. The table below lists some of the programs and outcomes against the framework’s principles for integrating care.

SCHN IC Program: Improving experiences and outcomes for children, families and carers

P E R S O N C E N T R E D

• More than 1500 children enrolled in IC Program initiatives

• Families saved more than 70,000 km in travelling to health professionals

• Families saved $217,930 in non-medical costs 1

• Single point of contact for families via Kids GPS Care Coordinators

• 24-hour hotline for families• Closer to Home, Closer to Care initiative

• Families are supported by local services• Reduction in presentations to SCH ED

for nasogastric (NG) replacement• 8.5% of new Kids GPS Care Coordination

enrolments identified as Aboriginal (Jan to March 2017); in comparison, 3.3% of inpatients and 1.9% of children presenting to ED identified as Aboriginal

• 29% of new Kids GPS enrolments were from CALD backgrounds; 43% of Kids GPS enrolments at CHW were from CALD backgrounds (Jan to March 2017)

• Shared care models now exist with LHDs to maintain feeding tubes locally.

• Programs tailored for identified groups, including children identifying as Aboriginal, children from culturally and linguistically diverse (CALD) backgrounds

TA RG E T E D

I N I T I AT I V E S O U TC O M E S


S H A R E D I N F O R M AT I O N

• 82% of health providers satisfied/very satisfied with care coordination service

• 72% providers agree communication has improved since care coordination started

C O L L E C T I V E LY AC C O U N TA B L E

• 48 babies supported post discharge• Treatment plans for babies with medical

complexity delivered locally• Over 400 remote patient conferences • 487 school absences prevented• 84 paediatric HealthPathways have been published

with 4944 hits on the platform in 12 months

• Grace Project connected babies with medical complexity to Kids GPS Care Coordinators

• Telehealth for remote consultations • Improved coordination and shared care models

with local providers

• Shared care plans for 310 children • Families have a single point of contact via the

Kids GPS Care Coordinator• My Health Memory helps families gather, store

and access information and communication

I N I T I AT I V E S O U TC O M E S

P R I M A RY C A R E B A S E D

• 1365 SCHN encounters avoided• 363 inpatient bed days prevented• 490 ED visits prevented• 440 day-only admissions prevented• More than $4.9m saved in hospital costs • ED presentations for Kids GPS patients more than halved • 84 paediatric pathways developed• 4944 hits on the website in 12 months

• Families, carers and stakeholders able to impact on design as the program was developed and implemented

• 80 children who did not have a GP have been linked with a GP in their local area

• 310 children now have a shared care plan• Support and education for children with

asthma, and their families and GPs • HealthPathways guide appropriate referrals

• Stakeholder feedback and data informed design, development and refinement

C O N T I N U A L LY I M P ROV E D


I N T E G R AT I N G C A R E I S P E R S O N - C E N T R E D A N D TA R G E T E D

Integrating care improves health outcomes, wellbeing and positive experiences with healthcare providers. Providing person-centred care means:

• supporting children of all needs, across all ages and settings

• recognising the unique needs of each individual child• meeting the needs of every child in the context of

their family and local community.

To do this, organisations must:

• work collaboratively with vulnerable populations to identify needs

• design services to meet individual needs• be agile enough to shift delivery of care to meet

the changing needs of individuals, and to deliver personalised, tailored care.

The SCHN IC Program identified children with medical complexity as a priority group needing initiatives for integrating care. From July 2014 to June 2015, there were 1709 children who were frequently re-admitted to the CHW or SCH, or attended the EDs multiple times.

To inform the development of the SCHN IC Program, this group of patients and their families were engaged in discussions about their individual needs and ideas for service design. This co-design process highlighted a number of challenges for families managing children with chronic and complex needs, including:

• the burden of caring• system navigation challenges• psychosocial impacts• other practicalities such as travel, respite and

caring for siblings.

Professionals described difficulties associated with:

• managing medical and clinical complexity (e.g. physical and neurodevelopmental disability, feeding difficulties, challenging behaviours and mental health issues)

• supporting families in challenging psychosocial contexts.

There was an opportunity to improve the experience and outcomes for children and families accessing services at SCHN by better coordinating and integrating care. This section of the report shows how the SCHN IC Program put patients and their families at the centre of their care planning, and outlines initiatives that directly targetted their specific needs.


>1500 C H I L D R E N E N R O L L E D I N I N T E G R AT I N G C A R E P R O G R A M S

E N C O U N T E R S AVO I D E D

363I N PAT I E N T B E D DAY S P R E V E N T E D

490E D V I S I T S P R E V E N T E D

440DAY- O N LY A D M I S S I O N S P R E V E N T E D

“

“

The more support you’ve got, the less you feel alone. You see the [care coordinator] waiting for you, they’ve contacted emergency; emergency already knows their needs. Having that plan turns the first conversation with the emergency doctor from a debate into a mechanical process.

Parent

1365


B E T T E R C O O R D I N AT E D , P E R S O N - C E N T R E D C A R E

To address the challenge that families face in navigating the health system, the SCHN IC Program utilises the circle of coordination (see Figure 1) for children with medical complexity. The circle of coordination ensures the child is at the centre of the system for integrating care. Families are guided by Kids GPS Care Coordinators, who are responsible for establishing the circle of coordination. The circle is formed by leads from the hospital, community and family, who ensure that all of those involved in the child’s healthcare needs are actively communicating.


F I G U R E 1 The circle of coordination (adapted from Cohen et al., 2012)6

K I D S G P S C A R E C O O R D I N AT I O N

Re-Engage

Act

NAVIGATION

• Information• Referral• Linking services

and resources

CARE PLAN IMPLEMENTATION

• Case Management• Clinical Services• Direct Consultation

PRACTICAL SUPPORT

• Family self-management• Provider education/training• Coaching, family education

and management

Assess• Family needs• Clinical needs• System support

needs

Evaluate• Goal attainment• Clinical outcomes• Family satisfaction• Unmet needs

Planning• Family goals• Services and resources• Initial care team• Team roles and

responsibilites

Coordinate and monitor• Service plans• Family goals• Care team roles• Clinical appointments• Resources

Family Lead

SCHN Lead Clinician

Community Lead Clinician

Child / Young Person


“ “Evaluation shows that parents value the Kids GPS care plans that are shared with them and with all healthcare providers involved in their child’s care.

The Kids GPS Care Coordinators work with families to understand their goals and inform the development of the care plan. They work with treating teams to identify opportunities to integrate and share care with local teams, streamline appointments, avoid unnecessary hospitalisations, and prevent ED attendances. The Kids GPS Care Coordinators support the maintenance of the circle of coordination until the team becomes well-established and self-sustaining.

The Kids GPS care plan guides the family in their decision-making. It helps them to determine which aspects of care can be delivered by whom, and builds the family’s confidence in their decision-making about the child’s healthcare needs. The family becomes part of a trusted support system that includes the community lead in the care team, consistent access to a local GP, and engagement with all relevant local health services.

The Kids GPS Care Coordinators are supported by:

• real-time ED flags• shared care coordination plans• revised policies, processes and procedures to

support practice, including induction processes• clear key performance indicators, which measure

both activity and outcomes of care. Evaluation shows that parents value the Kids GPS care plans that are shared with them and with all healthcare providers involved in their child’s care.

The Kids GPS Care Coordinators also had a significant impact on reducing the number of avoidable hospital encounters, as shown in Figure 2.


Jul0

5040302010

6070

90100

80

Aug Sep Oct Nov

2015/162016/172017/18

2015/162016/172017/18Target

Dec Jan Feb Mar Apr May Jun

Enco

unte

rs A

void

ed

Jul0

100

600

500

400

300

200

Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

Enco

unte

rs A

void

ed

F I G U R E 2 Kids GPS Care Coordination: impact on hospital encounters

Jul0

5040302010

6070

90100

80

Aug Sep Oct Nov

2015/162016/172017/18

2015/162016/172017/18Target

Dec Jan Feb Mar Apr May Jun

Enco

unte

rs A

void

ed

Jul0

100

600

500

400

300

200

Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun

Enco

unte

rs A

void

ed

F I G U R E 3 Cumulative Encounters Avoided – Comparison 2015/16, 2016/17, 2017/18


“ “Families of children with chronic and complex conditions get tired of telling the story over and over and over again to a new face all the time.

Parent, SCHN

S U P P O RT I N G FA M I L I E S 24 / 7

To help families manage medical complexity and care needs, children enrolled in Kids GPS Care Coordination who have feeding equipment needs have access to a 24/7 hotline.

Established in August 2016, the hotline supports families to follow their Kids GPS care plan - at any time, wherever they are. Care coordinators help families understand the urgency of their child’s needs and how to access the most appropriate service. The hotline has provided families with alternative ambulatory pathways, preventing unnecessary visits to the ED.

The hotline was well received by parents, who said it made them feel supported and that they were more equipped to make decisions about their child’s care. • 105 children enrolled in the 24/7

hotline program (August 2016 to June 2018)• 535 calls received by the hotline

(August 2016 to June 2018)• 140 ED presentations prevented to June 2018.

D E L I V E R I N G C A R E C LO S E R TO H O M E

The SCHN’s Closer to Home, Closer to Care initiative supports the management of paediatric conditions as close to home as possible. It also increases access to specialist care for children in regional, rural and remote areas. Children who need regular infusions or injections (e.g.tocilizumab and Humira) or who need NG feeding tubes can access such services at their local hospital or GP, easing the burden on tertiary hospitals and families.


I N D I G O ’ S S TO RY

Indigo, a nine-year old who has juvenile arthritis, needs monthly infusions. Every month, she would travel to Sydney from her home in Canberra, which meant time off work for her mother and time off school for Indigo. The three-hour car journey each way also caused Indigo significant pain, and she would often need a further two days off school to recover. Working with Indigo’s team in Sydney, her local hospital in Canberra, and the pharmacies at each hospital, the Kids GPS Care Coordinator arranged for Indigo’s infusions to be provided at her local hospital. Now Indigo travels just down the road, and she misses only half an hour of school each month.


“

“What the Kids GPS have done for my patients is give them a structured way of managing their child’s nasogastric tube, if it were to accidently fall out, which avoids them having to line up and spend a lot of time in the Emergency Department.

Specialist, SCHN

The SCHN IC Program team identified an opportunity to support the management of tube related issues in an ambulatory setting at St George, Sutherland or SCH. Each child discharged from SCH with a nutrition support device would:

• have an action plan for replacement of the nutritional support device

• where possible, have their nutritional support device replaced in an ambulatory setting

• if they are local to SESLHD, have their action plan agreed with St George or Sutherland Hospital, where local services are available

• have spares for the nutrition support device, and spares made available to the agreed local hospital.

A consistent approach to the management of NG tubes in an ambulatory setting has been established across SCH, St George and Sutherland hospitals. Care plans and consumables policies, which were jointly developed, are used in each setting, and clear referral pathways are agreed. The approach is now going beyond the ambulatory program, and is being trialled in other areas at SCHN with the support of the gastroenterology clinical nurse consultants. A carer education package about replacement of NG tubes is being developed and will be trialled at SCH. Since this program started, 179 children have had NG ED avoidance plans. At June 2018, 58 children from the SESLHD region had NG ED avoidance plans (Figure 4), and there was a reduction in presentations to SCH ED for NG replacement (Figure 5).

TA RG E T I N G S E RV I C E S TO M E E T S P E C I F I C N E E D S

In the South Eastern Sydney LHD (SESLHD), families shared anecdotes about children waiting several hours in EDs at SCH, St George Hospital or Sutherland Hospital to have their child’s nutritional feeding device replaced. The families of children requiring replacement of their gastrostomy tubes (G-Tube) were further frustrated that after waiting at their local hospital, they were inevitably required to transfer to SCH. In 2015, there were 240 presentations to SCH ED from children residing in the SESLHD catchment for issues related to their NG or G-tube.


Jul 16

Jun16

Jun17

May16

Apr16

Mar16

Feb 16

Jan 16

0

40

30

20

10

Aug16

Sep16

Oct16

Nov16

Dec16

Jan17

Feb17

Mar17

Apr17

May17

Jul17

Num

ber o

f Chil

dren

Jul 16

Jun16

May16

Apr16

Mar16

Feb 16

Jan 16

0

4.5

4.0

3.53.02.5

1.52.0

1.0

0.5

Aug16

Sep16

Oct16

Nov16

Dec16

Jan17

Feb17

Num

ber o

f Chil

dren

Median

Median

Jul 16

Jun16

Jun17

May16

Apr16

Mar16

Feb 16

Jan 16

0

40

30

20

10

Aug16

Sep16

Oct16

Nov16

Dec16

Jan17

Feb17

Mar17

Apr17

May17

Jul17

Num

ber o

f Chil

dren

Jul 16

Jun16

May16

Apr16

Mar16

Feb 16

Jan 16

0

4.5

4.0

3.53.02.5

1.52.0

1.0

0.5

Aug16

Sep16

Oct16

Nov16

Dec16

Jan17

Feb17

Num

ber o

f Chil

dren

Median

Median

F I G U R E 4 Number of children from SCH who have been given an NGT ED avoidance plan

F I G U R E 5 Number of children attending SCH for NG tube replacement, January 2015 to February 2017


In line with NSW MoH integrating care principles, SCHN service providers and clinicians are accountable to children and their families, and jointly responsible for children’s health and wellbeing. The co-design of the SCHN IC Program identified the need for alternative models of care that improve patients’ access to healthcare, and also improve communication with and among providers. Integrating care requires partnerships across service, program, organisation and sector boundaries. These partnerships require clear, formal processes for communication, and defined roles and responsibilities. This section outlines how collective accountability is embedded in the SCHN IC Program.

C O N N E C T I N G W I T H LO C A L C A R E P ROV I D E R S

With the increase in antenatal diagnostics and partnerships with maternity/obstetrics services, SCHN is increasingly able to plan for the delivery of babies with known medical conditions. Many of these babies will spend their first few months in hospital, with clinical teams coming to the child’s bedside. During the co-design of the SCHN IC Program, families shared that, over this extended stay, the hospital becomes a safe and known environment, and families felt dependent on the children’s hospital for all their healthcare needs. Many of the families expressed being fearful when their child was discharged to the community, where they felt nobody understood their child’s condition or treatment plan.

Even after children are discharged, families are expected to return repeatedly to the hospital for ongoing treatment and consultation, regardless of the impact on their daily lives. With health professionals and families focused on the child’s medical complexities, opportunities to engage with local providers can be overlooked – for example, for normal development checks, prevention activities such as vaccinations, and wellness support such as home visits and mothers’ groups. This limits opportunities to develop relationships with a local GP or community health centre. The Grace Project aimed to enrol all families of babies with medical complexity, whether diagnosed in utero or at birth, in the Kids GPS Care Coordination Service as soon as possible after birth. Babies who spent at least two weeks in the Grace Centre for Newborn Intensive Care at CHW and who required ongoing care from multiple teams within the hospital were linked with care coordinators based on the expected path for the child and the psychosocial needs of the family.

Since April 2016, Kids GPS Care Coordinators have supported 48 babies with complex needs, following their discharge from SCHN.

Under the Grace Project, the care coordinator works with the GP liaison nurses at Western Sydney LHD (WSLHD) to connect families to local health and community services, helping them to feel safe and supported outside of SCH. The care coordinator identifies which elements of the treatment plan can be delivered locally – for example, weekly weigh-ins, blood tests or blood pressure checks – and supports community providers to develop the required skill or protocols. This essential aspect of the care coordination role is key to developing positive relationships and understanding with local care providers.

I N T E G R AT I N G C A R E I S CO L L E C T I V E LY ACCO U N TA B L E


T E L E H E A LT H M O D E L S

The SCHN IC Program utilises telehealth to bring together families and their care teams, without the need for travel. A Network wide strategy delivers consultations remotely; to children in their homes, with their GPs, and at their local hospital. Telehealth is being rolled out across the Network with the support of the NSW Agency for Clinical Innovation.

The service will improve equity of access for children across NSW – whether the child lives in Far West NSW and needs regular reviews from five different teams at SCH, or lives five kilometres away from SCH, is on oxygen and in a wheelchair, and doesn’t have access to a family car.

As of June 2018, twenty SCHN services are using Telehealth and over 400 patient consultations have been conducted.

F I G U R E 5 Available telehealth models


“

“

I’d love a paperless system that meant that all her specialists were informed at the same time. You might not think that they’d need to know everything, but I emailed the neurologist about her involuntary movement and he prescribed Valium, but that affected her breathing, so I then had to contact the respiratory specialist… If all her specialists and doctors were linked up, that would take a lot of pressure off me.

Parent

I N T E G R AT I N G C A R E U T I L I S E S S H A R E D I N F O R M AT I O N

Innovations of the SCHN IC Program were co-designed with children, following in-depth conversations about their needs at different times. The voices of children with medical complexity, and their parents and carers, provided insights into priorities and information needs at different stages in the care journey. Families shared their frustration at being asked to repeat their story to multiple clinicians, and spoke of the reassurance they found in the folder they carried everywhere, containing doctors’ cards, letters and test results. Their sentiments are presented in Figure 6.


F I G U R E 6 Insights distinct to children with chronic and complex care needs, and their families and carers

degrees of support

the generational translation gap

the missing paper trail

free up my time for what really

matters

support me and show me I’m on the right track

connect the dots and catch

loose ends

simplify my records and data

management

see me as a person and

recognise what matters most

empower me without

overloading me

battle for timeliving in

perceptual uncertainty

lost in translation

information overload

recognise my experience

search for normalcy

say it once isolated and under pressure out of the loopappointment

frustrationlook beyond my

condition need to know

re-balance the care equation illusion of choice emergency

contingencyin the detail the whole picture

bridging the systems gap


These insights, from children and their families, informed the development of the My Health Memory (MhM) app. The MhM app provides:

• a convenient way for families to access their SCHN information

• a way for families to communicate with clinicians• an opportunity for families to streamline their

interactions with the Network.

Families told the integrating care team that they often feel overwhelmed by the information and communication they must coordinate to meet their child’s health needs. The MhM app supports families to manage that flow of communication within SCHN and across their local health services and community support agencies. A pilot implementation of the MhM app began in May 2017. Initially, users were able to view and request changes to appointments, and to communicate with clinicians via instant messaging. Messages were periodically recorded to the electronic medical record (EMR). As families and providers use the app, its developers, OneView Health, will respond to feedback and make iterative refinements.

Families will be able to use the MhM app to upload, tag, organise, search and store all documentation related to their child’s care in every setting – SCHN, local health services, primary care, the community, school and home – and at every stage of their healthcare journey. They will be able to build a complete profile of their child and the care they need on a daily, weekly and monthly basis. The child and family will have the power to decide what information to share and with whom.

Feedback indicated that families at different stages of care faced different challenges. This analysis led to recommendations to improve the integrating care model, by including better links with local hospitals and GPs, and the ability to adjust shared care plans in real time.

The MhM app is designed to support children and families at every stage of the healthcare journey.


F I G U R E 7 Overview of My Health Memory app

FA M I LY

U P LOA D E D

• What matters to me

• Photos• Videos

• SCHN Care Plan

• Evaluation Plan• Feeding device

management

• Referrals• Private

Specialist Letters

• Red flags• Alerts

• Private pathology and

• Radiology results

• Care goals• Medication Lists

• Respite application

• Centrelink letters

• Respite application

• Centrelink letters

• NDIS Plan• Physiotherapy

plan

• Clinical team contact details

• Communication

• Community clinician

• Contact details

• Hospital appointments

M Y H E A LT H M E M O RY A P P

A communication and information tool co-designed in partnership with families. All the information that matters to families about their child, accessible

via a smartphone, tablet or the web.

H O S P I TA L

U P LOA D E D


PA E D I AT R I C A S T H M A I N G E N E R A L P R AC T I C E

Anecdotal baseline information from SCHN care coordinators indicated that there was a group of children with asthma/viral induced wheeze (VIW) who were presenting to the ED multiple times. A new process was developed, where ED staff flag children who are re-presenting to the ED with asthma. These children, and their families, are connected with a Kids GPS Care Coordinator, who works with the family and their GP and/or paediatrician to manage their care closer to home. In this way, the child’s needs are met in the primary care setting, avoiding the need for them to continually present to the ED.

I N T E G R AT I N G C A R E I S P R I M A RY C A R E B A S E D

F R O M D E C 2 017 TO F E B R U A RY 2 018 ,

99 9 9 C H I L D R E N W I T H C O M P L E X A S T H M A W E R E R E F E R R E D TO A R E S P I R ATO RY C L I N I C A L N U R S E C O O R D I N ATO R .

6969 C H I L D R E N W I T H R E C U R R E N T P R E S E N TAT I O N S TO S C H N E D W I T H A S T H M A / V I R A L I N D U C E D W H E E Z E W E R E C O N TAC T E D BY K I D S G P S C A R E C O O R D I N ATO R S .

Children with medical complexity often have multiple providers and frequent contact with the health system.

Integrating care requires teams across settings to work together to provide the best care and outcomes for children and their families. These teams include providers in primary, acute, inpatient and social care. Integrating care across providers, organisations and sectors ensures children receive appropriate, high quality care, regardless of the service location. The SCHN IC Program focuses on achieving system change and transformation for these children, through partnerships with LHDs, Primary Health Networks (PHNs) and community organisations.

60% E D P R E S E N TAT I O N S W E R E R E D U C E D BY 6 0 % A F T E R I N T E R V E N T I O N


This integrating care initiative dramatically reduced the number of children presenting to ED with asthma/VIW.

Between December 2016 and September 2017, the number of children aged 2-16 with non-complex asthma or VIW who had presented to ED four or more times in a 12-month period was reduced by 60% six months before and after enrolment in Kids GPS Care Coordination.

Between December 2016 and July 2018, 99 children with complex asthma were referred to a respiratory clinical nurse coordinator.

F I G U R E 8 Care coordination for children with asthma/viral induced wheeze

ED staff identify children with asthma/viral induced wheeze with

repeat ED presentationsRefer to care coordinators

Family provided with standardised asthma/VIW pack (Asthma Action Plan, education,

discharge instructions)Letter to GP

Care coordinators contact family (via phone and letter)Facilitate review with GP

and/or paediatrician

Education sessions for ED staff and parentsEducation sessions and webinars for GPs in management of non-complex asthma.

Accredited under GP Continuing Professional Development Program


“ “I don’t know what clinical guidelines to use. It’s really hard to keep up with all the evidence. I guess I just use my experience.

General practitioner

S U P P O RT I N G P R I M A RY C A R E T H RO U G H H E A LT H PAT H WAY S

An important aspect of integrating care is supporting primary care to plan and coordinate patient care through the primary, secondary and tertiary healthcare systems within an LHD.

HealthPathways is an online information portal for GPs, providing localised clinical management guidelines and referral pathways for a range of conditions. Its overarching aim is to reduce clinical variation in health care. Via the HealthPathways online tool, GPs and other clinicians working in LHDs can access standardised, evidence-based health pathways. To develop the pathways – and redesign existing pathways as necessary – SCHN works in partnership with LHDs and PHNs. With WSLHD and WentWest, SCHN has made more than 84 paediatric pathways available on the HealthPathways portal, providing guidance to GPs for prevalent paediatric conditions, and referral pathways to access specialist support.

84PA E D I AT R I C PAT H WAY S M A D E AVA I L A B L E TO G P S V I A T H E H E A LT H PAT H WAY S P O R TA L

932 I N D I V I D U A L U S E R S O F T H E PA E D I AT R I C PAT H WAY S

4944V I E W S O F T H E PA E D I AT R I C PAT H WAY S

TOP PATHWAYS F O R A L L U S E R S : M I L E S TO N E S , D E V E LO P M E N TA L C O N C E R N S I N C H I L D R E N , U R I N A RY T R AC T I N F E C T I O N ( U T I ) I N C H I L D R E N

This experience will inform the paediatric pathways to be made available in South Eastern Sydney under an agreement between SCHN, SESLHD, Central Eastern Sydney PHN and St Vincent’s Health Network Sydney. Collaboratively developed paediatric pathways are also being promoted across the state to improve consistency in point-of-care decisions and access to appropriate treatment. The success of the asthma webinar has inspired a change to the launch of new paediatric HealthPathways. Newly published pathways will be accompanied by a webinar hosted by SCHN. This initiative will enable portal members to hear from and interact with the subject matter experts (consultant level) who developed the clinical content of the pathway.


B U I L D I N G C A PAC I T Y TO M A N AG E PA E D I AT R I C A L L E RG Y There is an increasing prevalence of food allergy in children, and the number of patients seen by the SCHN general allergy clinics has doubled in the last few years. Annual capacity across the Network is limited, and the waiting time for patients with food challenges has increased significantly. Wait lists are partly driven by a high number of inappropriate referrals from GPs and paediatricians, who would benefit from having access to education and guidelines by the Australasian Society of Clinical Immunology and Allergy. There continues to be a lack of integrated, consistent care for children with potential or diagnosed food allergies.

In response, a team from St George Hospital, Sutherland Hospital, SCH, and Allergy and Anaphylaxis Australia has developed a whole-of-system approach to manage the increasing numbers of children requiring management for allergy in the South Eastern Sydney region. The approach has included publishing paediatric allergy pathways to the HealthPathways portal to help GPs manage allergy in the primary care setting. A low-risk food challenge clinic has been established at Sutherland Hospital to improve timely access for patients and to relieve the waiting list pressure for food challenges at St George and SCH. The approach is an example of integrating care in practice.

I N T E G R AT I O N AC RO S S H E A LT H A N D S O C I A L C A R E

The impact of the psychosocial circumstances surrounding children with medical complexity is a significant concern. With increasing numbers of children with medical complexity residing in rural areas, families are increasingly reporting significant challenges related to long-distance travel and the impact this has on the family unit.

Responding to these concerns in the Murrumbidgee LHD, an extended care team model was developed for children living with medical and psychosocial complexity in rural areas.

Models of care for children in Murrumbidgee have built on established care coordination and central intake referral systems in the adult sector. Local care coordinators (paediatric clinical nurse specialists) based in Wagga and Griffith are funded by the Murrumbidgee LHD and focus exclusively on paediatric patients within the district’s broader care coordination framework. The Paediatric Care Coordination Service aims to improve equitable access to appropriate care for children with medical complexity in rural areas, by:

• developing shared care plans that improve communication, support decision-making and facilitate integration

• ensuring safe and coordinated transfer of care, so the care provided is not determined by location

• promoting self-management and empowering children and their families as informed and active participants in their care

• supporting local capacity to provide safe, accessible, timely, sustainable and improved quality of care.


P R E V E N T I N G E M E RG E N C Y D E PA RT M E N T P R E S E N TAT I O N S

To develop the SCHN IC Program, ED and admissions data was analysed to identify target groups of children, especially those who frequently present to the SCHN (four plus visits per year). This group accounts for 10% of total ED presentations for CHW (total 4500 per annum) and 15% for SCH (total >5000 per annum). By identifying children in this group, Kids GPS Care Coordinators can work with their treating teams and families to develop individual ED avoidance plans, which can lead to a reduction in the number of ED presentations.

Kids GPS Care Coordination enrolment data was linked to other NSW Health datasets by the Centre for Health Record Linkage (CHeReL, the independent linkage authority), and used to monitor performance and outcomes across a range of indicators, as outlined in the Integrated Care Evaluation Framework. Prior to Kids GPS Care Coordination, ED visits for the children presenting to ED four plus times a year were on the rise. This trend reduced significantly after the SCHN IC Program was introduced, with the following results:

• the increasing number of ED visits in the years prior to Kids GPS Care Coordination came to a halt and overnight admissions decreased

• length of stay and total length of stay per patient decreased.

Figure 9 shows the average year-on-year difference in ED presentations for children with four plus presentations who were supported by Kids GPS Care Coordination.

To build on this achievement, SCHN has developed an ambulatory dashboard, which provides the Kids GPS Care Coordinators with a summary of potentially avoidable admissions and ambulatory sensitive presentations. The dashboard enables the team to identify trends and support a systemic approach to reducing the number of preventable ED presentations.

3-4 years prior

2-3 years prior

1-2 years prior

following GPS Care

Coordination

-1.0

2.5

2.0

1.51.00.5

-0.50.0

-1.0

-0.5

??????

??????

??????

??

F I G U R E 9 Year on year difference in ED presentations

ED p

rese

ntat

ions

per

year


B U I L D I N G C A PAC I T Y I N W H O L E - O F - FA M I LY O B E S I T Y M A N AG E M E N T

The SCHN IC Program includes an initiative to support local communities to run family-centred obesity management programs, to help prevent obesity and patients’ eventual need to access secondary and tertiary services. SCHN’s whole-of-family obesity management program aims to reduce the projected increased prevalence of obesity in children, using a healthy lifestyle approach. It depends on strong partnerships with local communities.

The SCHN initiative delivers a train-the-trainer, multidisciplinary educational roadshow to support LHD staff to deliver family-centred obesity management programs. It includes the distribution of a resource pack, which contains contributions by content experts, including specialist paediatricians, a specialist weight management clinical nurse consultant, a physiotherapist, dietitians and a clinical psychologist.

The obesity management initiative brings services closer to home, and utilises the primary care setting to improve the health of local communities.


L E A D E R S H I P, C A PA B I L I T Y A N D C U LT U R E C H A N G E

The SCHN IC program has achieved significant and positive change for children, families and the health system. This has been achieved by working in partnership with stakeholders, enabling local leaders, embedding systems for integrating care, and building capability to drive improvement.

The SCHN IC Program was designed with a wide range of stakeholders, who continue to inform the evaluation and redesign of initiatives and care models. The program is committed to ongoing improvement, and has put in place processes for routine outcomes measurement and reporting. Practitioners obtain regular information about child, family and service outcomes, and are supported to engage in improvement. The SCHN IC Program works with partner agencies to monitor, evaluate and make further improvements to integrating care.

SCHN is a leader in integrating care in NSW. The SCHN IC Program has had the opportunity to share lessons learnt from the development of the program via international and national forums and publications.

P R E S E N TAT I O N S

• Caring for Country Kids Conference, Alice Springs 2016, Connecting the family with care: integrated care models for rural children. Lisa Altman.

• MP4 Forum, Sydney 2016,Kids GPS Integrated Care. Lisa Altman and Naomi van Steel.

• APAC Forum, September 2016, Kids GPS Integrated Care – Leaving the ivory tower [Poster].

• NSW Health Innovation Symposium, Sydney 2016, SCHN Kids GPS Integrated Care. Lisa Altman.

• World Congress of Integrated Care, Wellington NZ2016, Kids GPS Integrated Care – Leaving the ivory tower. Lisa Altman.

• Institute for Healthcare Improvement National Forum, Orlando 2016. Connecting care for children. Lisa Altman.

• International Foundation for Integrated Care, Dublin Ireland 2017, A view of the whole child – Patient co-design of a communication and information tool to support complex care. Lisa Altman.

• Asia Pacific Conference on Integrated Care, Brisbane 2017, Symposium: Practical insights from paediatric integrated care. Lisa Altman, Christie Breen, Dr Joanne Ging, Dr Sue Woolfenden.

• TSANZSRS Annual Scientific Meeting, Adelaide, 2018, Evaluation of an integrated paediatric asthma management program: preliminary data. Dr Nusrat Homaira.

I N T E G R AT I N G C A R E P R O M OT E S CO N T I N U O U S I M P R OV E M E N T


P U B L I C AT I O N S

Altman L, Zurynski Y, Breen C, Hoffmann T, Woolfenden, S (2018). A qualitative study of health care providers’ perceptions and experiences of working together to care for children with medical complexity (CMC). BMC Health Services Research, 18(1), 70.

Altman L, Breen C, Ging J, Burrett S, Hoffmann T, Dickins E, et al.. “Dealing with the Hospital has Become too Difficult for Us to Do Alone” – Developing an Integrated Care Program for Children with Medical Complexity (CMC). International Journal of Integrated Care. 2018;18(3):14. DOI: http://doi.org/10.5334/ijic.3953

Altman L, Breen C, Deverell M, Ging J, Woolfenden S, and Zurynski Y, et al.. “Significant reductions in tertiary hospital encounters and less travel for families afterimplementation of Paediatric CareCoordination in Australia” – BMC Health Services Research (2018) 18:751https://doi.org/10.1186/s12913-018-3553-4


Innovative approaches to integrating care must be sustainable. Effective integrated practice is embedded in everyday care and usual business processes. It requires a prepared and equipped workforce, supportive processes and systems, and standardised business practices. In clinical environments, this can include alert systems, recall and reminder systems, and clinical pathways.

O U R F U T U R E WO R K

There is still room for improvement in the SCHN IC Program. There are opportunities to progress existing initiatives, to extend into new clinical or geographical areas, and to consider broader paediatric populations. Sustainability of SCHN’s success in integrating care depends on appropriate resourcing, in the context of ever-increasing demands, and ensuring systems continue to be embedded into everyday care. Embedding referral criteria, model of care guidelines, and communication tools into everyday clinical systems will support consistency and reduce variability in practice. Partnerships with other services will enhance the care experience and continue to improve outcomes for children, closer to home.


O U R F U T U R E P R I O R I T I E S

Initiatives to ensure the continued success of integrating care at SCHN are outlined below, with reference to NSW MoH principles for integrating care.

C O N T I N U A L LY I M P ROV E D• Continue to work with children and families to co-design strategies for integrating care.• In 2019, evaluate all SCHN integrating care initiatives.

P E R S O N C E N T R E D• Support care closer to home.• Support families’ autonomy and confidence.• Continue to help families navigate the health system. • Work with children and families to proactively identify areas for improvement, and codesign strategies

for integrating care.• Develop a trusted platform to educate practitioners and families on paediatric health, development and wellbeing.

TA RG E T E D• Design integrating care initiatives for other paediatric populations (beyond children with medical complexity). • Focus on the Early Years of childhood. • Deliver services to vulnerable families.

C O L L E C T I V E LY AC C O U N TA B L E• Ensure all health professionals and relevant stakeholders involved in the care of a child have access to care plans.• Expand and improve telehealth.• Continue to work with stakeholders to design and evaluate strategies for integrating care.

S H A R E D I N F O R M AT I O N• Ensure EMRs indicate that a patient is engaged in Kids GPS Care Coordination or another integrating care initiative.• Share care plans electronically.• Ensure all health professionals involved in the care of a child have access to care plans.• Continue to consult with families on the MhM app, and develop it to meet their needs. • Improve consistency in the collection and analysis of data, to support ongoing evaluation of integrating care initiatives.

P R I M A RY C A R E B A S E D• Strengthen engagement with general practice, by working with PHNs, GP leaders and GP clusters. • Collaborate with GPs on future initiatives for integrating care.• Collaborate with GPs and specialists on HealthPathways.• Establish paediatric GP outreach hubs to build capacity in the GP workforce.• Provide education to GPs and paediatric services in LHDs to administer specialist drug infusions and injections to

reduce day-only admissions to SCHN.


SCHN has embedded its integrating care initiatives to ensure practices and initiatives are sustainable over the long term. Priorities for the sustainability of integrating care are set out below.

The program for integrating care at SCHN is among the most advanced in the state.8 This transformational work built on the foundation of cultural change already taking place in our organisation, where patient focus and patient involvement in care decisions is paramount.

The SCHN IC Program was designed in partnership with children, families and carers. A strong consumer focus has ensured its initiatives are well-designed and acceptable to families, and that they achieve positive outcomes for children and their families. Working together with other LHDs, PHNs and community organisations has resulted in a service system that is now more prepared and equipped to integrate care.

Integrating care at SCHN has strong foundations in the Kids GPS Care Coordination team, and is expanding across the Network, across LHDs and partner organisations. Kids GPS Care Coordination has demonstrated its value to our patients, staff and partner LHDs through the success and spread of numerous initiatives and models of care, and positive outcomes for children, families and services. SCHN has allocated recurrent funding for the role of Kids GPS Care Coordinators due to their clear positive impact on care experiences and outcomes for children and the health system.

S U S TA I N A B L E• Identify demand for Kids GPS Care Coordination Service. • Ensure Kids GPS Care Coordination Service is well resourced. • Strengthen links between Kids GPS Care Coordinators and medical teams .• Promote the role of Kids GPS Care Coordinators. • Embed processes and document templates.• Support established models of care, and support their spread into other clinical and geographical areas.• Review criteria for patient inclusion in Kids GPS Care Coordination to ensure it is used consistently,

efficiently and effectively.• Review the roles and responsibilities of Kids GPS Care Coordinators. • Ensure a shared understanding of the roles of Kids GPS Care Coordinators.


Key to integrating care for children with medical complexity are:

• care coordination • a single care plan for each child• a central repository of information• improved communication channels,

such as telehealth and case conferencing• clear guided referral pathways• access to appropriate care that is as

close to home as possible.

SCHN has embedded supportive processes and practices for integration into everyday care. This report has highlighted the achievements of focused work for integrating care at SCHN and presented opportunities to sustain and extend SCHN’s IC Program.

SCHN looks forward to the next phase of further integrating care for our patients and families, and to providing leadership for innovation and integrating care in NSW.


To the families and children who so generously gave their time and insights.

To the families who allowed us to use their stories within this report. Names have been changed to protect privacy where requested. We are grateful for your feedback and your generosity.

To the original authors of SCHN’s integrated care strategy, led by Michael Brydon, Sandra Wales and Tim Hoffmann, who provided the vision for SCHN to lead the way in paediatric integrated care.

To the NSW Health Planning and Innovation Fund for the funding that enabled these achievements.

To SCHN for the funding commitment to establish the Kids GPS Care Coordination Service as a permanent service for our patients and families

To the Integrated Care Team at the NSW MoH who continue to provide support, resources and tools to improve the implementation of integrating care across SCHN.

T H A N K YO U

E X E C U T I V E S P O N S O R S

Sydney Children’s Hospitals Network Michael Brydon Emma McCahon Cheryl McCullagh R E P O RT A U T H O R S

Lisa AltmanChristie BreenEmma DickinsSue WoolfendenYvonne Zurynski

PA RT N E R S

South Eastern Sydney Local Health DistrictMichelle Jubelin

Central and Eastern Sydney Primary Health NetworkBrendan GoodgerBelinda Michie

WentWest, Western Sydney Primary Health NetworkIan CorlessMelissa Gibson

Allergy and Anaphylaxis AustraliaJody AikenMaria Said

SCHN ManagementChristie BreenSara Burrett Georgette Danyal Joanne GingTim Hoffmann

SCHN Integrated Care LeadsLisa AltmanSue Woolfenden


Australian Paediatric Surveillance UnitAmy PhuEdith SalangaYvonne Zurynski

Western Sydney Local Health DistrictJasmine GlennanVictoria NesireNaomi van Steel

Murrumbidgee Local Health DistrictBarb MontcrieffNicole MyersFiona Renshaw

Murrumbidgee Primary Health NetworkJenni Campbell

Asthma Foundation NSW and QueenslandAnthony Flynn

SCHN Integrated Care Project TeamRichard KnightEmma DickinsCarolyn GethingsKatrina TopferKristen Brown

Kids GPS Care CoordinationJennifer Andresen Mary CorbettSarah DonnellyCameron HarwoodElizabeth IngoldGerry KeenanYolanda Miceli

Kids GPS Ambulatory ServiceNadine ShawJulie Hollingsworth

A L L Q I A N D G E N M E D T E A M S AC RO S S S C H N

Julie FriendshipAndrew CoeLaura VincentAnne HurstPauline BestMargaret NorrisPeta GallagherRebecca KellyChristine LauAlison KennedyAlison Loughran-FowldsKaye SpenceMae RafrafMichael FasherNicola McKayVishal GuptaJennifer MulliganAngela McColeNicole MyersDaniel HayesJohn PreddyLesley JeffriesLaura GriffinChristine BurnsMelinda GraySandra WalesCath SumskyLouisa OwensMichael PlaisterNusrat Homaira

C O N S U LTAT I O N S E RV I C E S

How to ImpactOneView HealthAccess EditingEmerson HealthHealthy Partnerships

* All SCHN staff who completed the survey


I N T E G R AT I N G C A R E F O R C H I L D R E N


1 NSW Ministry of Health 2014. NSW State Health Plan: Toward 2021. Accessed November 2016 at http://www.health.nsw.gov.au/statehealthplan/Pages/NSW-state-health-plan-towards-2021.aspx

2 NSW Ministry of Health 2014. NSW State Health Plan: Toward 2021. Accessed November 2016 at http://www.health.nsw.gov.au/statehealthplan/Pages/

3 NSW-3 NSW Ministry of Health [In print – 2018] NSW Health Strategic Framework for Integrating Care.

4 NSW Integrated care strategy [Internet Jul 2016]. Accessed December 2017 at http://www.health.nsw.gov.au/integratedcare/Pages/integrated-care-strategy.aspx

5 Deloitte Access Economics 2017. Formative Evaluation of the Integrated Care Strategy. Integrated Care Strategy project summary – Sydney Children’s Hospital Network. Deloitte Touche Tohmatsu.

6 Adapted from Cohen E, Lacombe-Duncan A, Karen Spalding K, MacInnis J, David Nicholas D. Integrated complex care coordination for children with medical complexity: A mixed-methods evaluation of tertiary care-community collaboration. BMC Health Services Research 2012, 12:366

7 NSW Ministry of Health [In print – 2018] NSW Health Strategic Framework for Integrating Care.

8 Deloitte Access Economics 2017. Formative Evaluation of the Integrated Care Strategy. Integrated Care Strategy project summary – Sydney Children’s Hospital Network. Deloitte Touche Tohmatsu.


SUI5

4022

609

Documents

INTEGRATING CARE FOR CHILDREN - Sydney Children's ... · integrating care for children: at a glance The SCHN IC Program achieved outcomes that are directly related to the NSW MoH