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“I Could Stop and Breathe”: Early Implementation Results of a Short-Term Care Coordination Model for Children with Medical Complexity Cover

“I Could Stop and Breathe”: Early Implementation Results of a Short-Term Care Coordination Model for Children with Medical Complexity

Open Access
|Mar 2025

Figures & Tables

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Figure 1

The Hunter New England Local Health District of New South Wales, Australia.

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Figure 2

The HNEkids Complex Care Coordination Model of Care.

Table 1

Eligibility criteria for the Model of Care.

To be eligible for the Model, children must meet all of the following criteria.
Children must:
  • Access HNEkids health services within HNELHD.

  • Have a diagnosis expected to last greater than 12 months.

  • Need specialty medical support under three or more specialty teams dealing with different organ systems (this can be predicted for infants).

  • Have no existing key person already coordinating their care within a multidisciplinary team.

  • Have the potential for a more coordinated approach in their care.

Table 2

Referral prioritisation tool.

PRIORITISATION CATEGORYSCORE
VulnerabilityAboriginal and/or Torres Strait Islander
Living in out of home care
Lives in a rural or regional community
A refugee/asylum seeker
Culturally and linguistically diverse background
Homelessness
Gestational age <32 weeks
Other
InstabilityHas the child had, or is expected to have, more than one emergency presentation in 12 months?
FragilityHas the child had more than 5 hospital admissions in 12 months or 30 inpatient days in 6 months?
Note: Overnight Accommodation, Day Medical and Day Surgical do not count as inpatient stays.
IntensityDoes the child have an interventional health care need and requires a technology or procedure in their home.
ComplexityHas the child had greater than 20 medical appointments in 12 months?
Do not include allied health visits or any visits that could be accessed in the community but were attended at a HNELHD facility due to convenience (i.e immunisation). Appointment no can be predicated for infants.
Total score
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Figure 3

The role of the Paediatric Care Coordinator.

Abbreviations used within figure:

  • HNELHD: Hunter New England Local Health District

  • JHCH: John Hunter Children’s Hospital

  • SCHN: Sydney Children’s Hospital Network

  • NDIS: National Disability Insurance Scheme

  • NGOs: Non-government organisations

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Figure 4

What families can expect during the Intensive Phase of the Model.

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Figure 5

Results of Normalization Measure Development (NoMAD) Survey.

Abbreviations used in figure:

  • HNEkids CCC Service: HNEkids Complex Care Coordination Service

Table 3

Written feedback from health staff.

  • “This is a worthwhile service for our kids and families.”

  • “This service has been invaluable for the care of my complex patients who otherwise get lost amongst the many services they access within healthcare.”

  • “The Network has been a great source of new info for me. It has made coordinating care easier for the kids I look after – even if they haven’t gone through the actual intensive care coordination with the Care Coordinator.”

  • “I can already see how this service is helping to make clear who is doing what. It’s accountability, plus support. And I can see it is sustainable. It’s great to be part of the solution!”

DOI: https://doi.org/10.5334/ijic.8975 | Journal eISSN: 1568-4156
Language: English
Submitted on: Aug 16, 2024
Accepted on: Mar 13, 2025
Published on: Mar 26, 2025
Published by: Ubiquity Press
In partnership with: Paradigm Publishing Services
Publication frequency: 4 issues per year

© 2025 Stephanie Hodgson, Ashleigh Griffiths, Christophe Lecathelinais, Camilla Askie, published by Ubiquity Press
This work is licensed under the Creative Commons Attribution 4.0 License.