A care coordinator’s role is to ensure information is communicated to the right people, at the right time and that information is used to provide consistent care, which is safe, appropriate and effective.1
The information presented below is intended to support the NSW Paediatric Rehabilitation Services (PRS) to ensure key elements of coordination are completed at each site, ensuring equity for consumers and alignment with the minimum standards. It is also intended to support resourcing which may be required for services to achieve “improved coordination” as outlined by the minimum standards and Henry Recommendation 50.2
Care coordination supports patients and their families through their rehabilitation journey. It is intended to prevent delays and disruption in care and ensure all relevant clinicians are involved in the provision of care. This requires purposeful organisation of care and sharing of information between relevant clinicians.1,3
Currently, the way in which the three NSW PRS provide care coordination differs. No site has a dedicated care coordinator role.
Primary purpose of PRS care coordinator roles
The PRS care coordinator role is responsible for ensuring a high level of coordination between the tertiary paediatric rehabilitation service and other services or clinicians that a child or young person may require during their rehabilitation journey. This is done through adherence to the minimum standards for children and young people accessing both inpatient and outpatient rehabilitation services.
The role requires a high level of clinical experience and expertise in rehabilitation. This allows the coordinator to provide clinical and educational advice, as well as supporting families and other health service providers.
The care coordinator roles should be part of a larger team that is responsible for the development, implementation and ongoing review of various service models outlined in the minimum standards, including outreach clinics and virtual care.
Key elements of care coordinator roles at PRS sites
During inpatient care
- Act as point of contact for family during inpatient admission and support family decision making using information sheet: inpatient rehabilitation for children and young people in NSW.
Related minimum standards: 1.2, 1.3
- With consent from family, contact the local health district (LHD) to determine if transfer to local inpatient facility is an option (if appropriate).
Related minimum standards: 1.4, 1.7
- Provide ongoing updates to the LHD team during tertiary inpatient admission, as per transfer of care communication plan
Related minimum standards: 1.6
- Ensure LHD teams are provided with education and hand over case conferences (as per transfer of care communication plan).
Related minimum standards: 1.6
- Ensure inpatients have a weekly multidisciplinary case conference, including updating of goals.
Related minimum standards: 1.7
- Ensure inpatient discharge summary is complete and provided to family and other relevant parties on day of discharge.
Related minimum standards: 1.8
- Ensure local school teachers are involved in transition to community (where appropriate).
Related minimum standards: 3.3
During outpatient care
- Contact parent/carer of newly referred children to ensure referral information is complete, including a list of local care team members, and provide family with a point of contact at PRS.
Related minimum standards: 1.1, 1.2
- Ensure clinic letters are provided to family and relevant parties within two weeks of the clinic appointment.
Related minimum standards: 1.9
- When requested, provide families with access options for local team to attend PRS clinic appointment, including making sure family are aware of financial implications.
Related minimum standards: 2.2
- Coordinate PRS outreach clinics in conjunction with LHD services and teams, including consideration for LHD educational opportunities
Related minimum standards: 3.1
Clinical indications where care coordination is recommended
Not all children and young people accessing the PRS require the support of a coordinator to experience coordinated care. However, the following list may be used to identify patients who may benefit most from the support of the care coordinator. In general the greater number of items, the more complex a patient is and the more likely care coordination will be required.
Recent healthcare use
A diagnosis lasting at least 12 months, and one or more of the following in the past 12 months:
- at least one intensive care unit admission
- at least two inpatient admissions
- at least six emergency department admissions
- at least three different subspecialist outpatient appointments.
Other factors (including but not limited to)
- Aboriginal and/or Torres Strait Islander people
- People from a culturally and linguistically diverse background
- People from a refugee or asylum seeker background
- Families with complex social history such as out of home care, financial distress, family psychosocial or mental health concerns.
- Agency for Healthcare Research and Quality. Care Coordination [Internet]. Rockville, MD; Department of Health and Human Services; 2014 [Updated 2018 August; cited 2022 August 18].
- Henry, R. Review of health services for children, young people and families within the NSW Health System. [Updated 2019 December; cited 2022 June 1].
- NSW Health Patient Flow Team. Care Coordination [Internet]. Sydney: NSW Ministry of Health; 2017 [updated 2017 May 16; cited 2022 August 18].