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"Dealing with the Hospital has Become too Difficult for Us to Do Alone" - Developing an Integrated Care Program for
Lisa Altman1, Christie Breen1, Joanne Ging1
1Sydney Children's Hospitals Network, AU.
Insights
The Kids Guided Personalised Services (GPS) Integrated Care Program improved healthcare for children with medical complexity (CMC) by enhancing communication and streamlining care. This initiative reduced emergency department visits and hospital admissions through integrated, shared care models.
Area of Science:
- Healthcare Management
- Pediatric Care
- Integrated Health Systems
Background:
- Children with medical complexity (CMC) require specialized, long-term care from multiple providers.
- Existing healthcare systems often present challenges in coordinating care for CMC.
- The Kids Guided Personalised Services (GPS) Integrated Care Program was developed to address these challenges.
Purpose of the Study:
- To describe the development and implementation of the Kids GPS Integrated Care Program over its first 18 months.
- To improve the healthcare experience and communication for families of CMC.
- To streamline the provision of care for CMC through a shared care model.
Main Methods:
- Development of shared care models integrating local health services with tertiary hospitals.
- Implementation of change through 5 individual project streams.
- Extensive formative evaluation to understand all stakeholder perspectives.
Main Results:
- Comprehensive system change and transformation achieved.
- Reduced presentations to the Emergency Department (ED).
- Decreased avoidable hospital admissions and patient travel time.
Conclusions:
- Key enablers were established for program success.
- The program effectively supports families caring for CMC.
- Engaging primary healthcare providers remains an ongoing challenge.
Introduction:
Children with medical complexity (CMC) require highly specialised care, often from multiple providers and over many years. This paper describes the first 18 months of development of the Kids Guided Personalised Services (GPS) Integrated Care Program (the Program). This Program aims to improve health care experience; communication and to streamline provision of care.
Discussion:
Key enablers across the Program were put in place and 5 individual project streams were used to implement change. An extensive formative evaluation process was undertaken to truly understand all perspectives in developing the Program.
Conclusion/Key Lessons:
This Program supports families who are caring for CMC by developing shared care models that bring together local health services with the tertiary hospitals. The methodology used has resulted in comprehensive system change and transformation; reduced presentations to the Emergency Department (ED), avoidable admissions and travel time. A challenge remains in meaningfully engaging primary health care providers.
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