Our project connects children and families with care and services earlier and more effectively through developmental and psychosocial screening. Guidelines and training will further support families who need help engaging with and getting what they need from providers.
The Western Sydney Local Health District (WSLHD) Child and Family Health service provides children and families in Western Sydney with equitable and timely access to care and services by providing consistent care coordination. We coordinate care for children and families with complex developmental and psychosocial needs to ensure they can access the right services, at the right time. We identify these needs, facilitate access and liaise with other health professionals on behalf of the child and their family. However, the way we do this varies depending on the clinician assigned to the family, and the family’s experience and confidence with the health system.
The need for care coordination in Western Sydney is high – we have one of the most culturally diverse populations in NSW, including many Aboriginal families and people from culturally and linguistically diverse backgrounds, who can have varied and complex healthcare needs.1 Australian Early Development Census2 data suggest that in parts of Western Sydney, developmental vulnerability is 3 times higher than the state and local health district average.
Improving access to support for children and families
Extensive consultation conducted with Child and Family Health service clients and staff gave us a thorough picture of the challenges and where we could improve. We identified that:
- care coordination delivered by clinicians and clinical teams varied widely
- clients had difficulty accessing support
- staff did not fully understand what support clients could access and what their scope of practice was in connecting clients to services
- collaboration and communication between healthcare providers could be improved.
Our clients felt the responsibility was placed on them to navigate services and to access support. Yet, 67% were unsure what services were available or how to access them. They experienced multiple wait times because their needs had not been identified early (46% of clients waited between 3 and 24 months for a referral to a second service). Only 18% of families felt their health professionals worked together as a team, and 62% of clients reported they would like more help to access services.
More than half of our clinicians felt overburdened and burnt out. Many did not view care coordination as part of their role. Clinicians reported they were learning how to coordinate care on the job, and only 13% reported they had undertaken necessary training. They also said that collaboration was very important, yet 77% admitted that they did not always do it. Half of our staff also reported low confidence in their understanding of referral pathways.
We concluded that implementing some service-wide approaches to providing care coordination could improve clinical outcomes and the experiences of children, their families, and staff. The service delivery and budgetary impacts of increased care coordination done without the client present, which is out of scope of our activity-based funding model, would need to be considered for any solutions we developed.
Proactive screening and specialised training
Our project team was guided by a Child and Family Health Steering Committee. We agreed to focus initially on the Merrylands and Auburn community health centres. Extensive consultation included staff focus groups, surveys and interviews, as well as client interviews and surveys. We analysed issues raised during consultation thematically, and prioritised them with input from staff and clients. We refined and prioritised solutions with staff and Child and Family Health service management.
We decided to implement two solutions:
- Proactive developmental and psychosocial screening to support early identification: Child and Family Health Allied Health services will undertake proactive screening at the point of referral to identify children and families who need other services, such as other Child and Family Health services, NDIS services or other services in the community. We have developed and trialed a screening tool – when finalised, the tool can be used at all of our centres.
- Care coordination practice guidelines and staff training to help families engage with supports: Staff will be trained in care coordination and supported with referral guidelines, as well as intake and referral checklists. The Child and Family Health service will develop practice guidelines to define the roles of clinicians in providing care coordination. Improvements to multidisciplinary consultation and informal relationships will improve collaboration among staff. This solution will be progressed when we receive direction from the steering committee.
View this project's poster from the Centre for Healthcare Redesign graduation August 2025.
References
- Australian Bureau of Statistics. Aboriginal and Torres Strait Islander Peoples. Belconnen, ACT: Australian Bureau of Statistics; 2021. Available from: https://www.abs.gov.au/statistics/people/aboriginal-and-torres-strait-islander-peoples
- Australian Department of Education. Australian Early Development Census. Canberra, ACT: Australian Department of Education; 2021 [updated 13 June 2025]. Available from: https://www.education.gov.au/early-childhood/early-childhood-data-and-reports/australian-early-development-census-aedc
