Minimum standards for coordinated delivery of paediatric rehabilitation in NSW Health

Published: December 2022

These minimum standards are intended to set the benchmark for the coordination of services providing paediatric rehabilitation in NSW Health. These services include the NSW Paediatric Rehabilitation Services (PRS) and local health districts (LHDs).

It should be noted that not all minimum standards apply to both PRS and LHDs.

There are a total of 18 minimum standards that have been grouped into three categories:

  1. Care coordination
  2. Virtual care and electronic medical records
  3. Care across the continuum

1. Care coordination

1.1 Referral pathways into the PRS are clearly documented and accessible for LHD and primary care clinicians, including GPs.

The criteria and relevant forms to refer a patient to tertiary PRS in NSW are easily understood and readily available and accessible to any doctor who would like to refer a patient.

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1.2 Families, in both inpatient and outpatient services, have access to a care coordinator or single point of contact from their current care team.

Families have access to one clinician who can support the family in their rehab journey and assist with any troubleshooting. This clinician should always be part of their current team, so may change with changes to treating team, e.g. from the PRS to LHD. The role may be a dedicated role or position, such as a case manager, or may be included as part of the work of a team member.

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1.3 All families have access to supported and informed decision making to determine which pathway is best for their child and individual situation.

Families of children receiving paediatric rehabilitation in NSW have access to information that is evidence-based and easy to understand when making decisions about their child’s care. They are given the opportunity to ask questions when deciding about what is best for their individual situation.

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Jack’s story

Jack is receiving inpatient rehabilitation at a PRS facility.

Jack’s mum is given the opportunity to understand the rehab options available for Jack and his family and the implications they may have for his recovery. She decides the family needs to be reunited at home and Jack will continue rehab three times per week at the local hospital. She is aware and understands this may impact the speed of his recovery, but she feels supported by the team. She is comfortable that she has made the right decision for her family and individual needs.

1.4 PRS clinicians contact LHD clinicians to discuss future local capacity, potential therapy options and determine time frame for handover process (minimum standard 1.6), where applicable. This discussion should be when the child or young person is transferred from the acute Sydney Children’s Hospital Network or Hunter New England LHD team to the PRS inpatient team.

With the family’s consent, PRS inpatient team contacts the local or LHD team early in the admission. This timing should be when the care is transferred from their acute tertiary team (such as trauma or neurosurgery) to the PRS team. Both teams discuss patient status and local therapy options to identify suitability and timing of transfer based on patient’s goals and status.

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Sally’s story

Sally is injured in a car accident. She is admitted to John Hunter Children’s Hospital under the trauma and neurosurgery teams. She remains under the care of these two teams for one month. After that, her care is transferred to the rehab team (PRS Newcastle). Once PRS Newcastle has taken over Sally’s care, they contact clinicians in Sally’s local area to discuss local therapy capacity and options for Sally and her family.

1.5 Current care team complete weekly case conferencing for all paediatric rehabilitation inpatients with an estimated admission of over one week, and document the discussion in the medical record.

The weekly case conference is attended by the patient’s treating team. The discussion is documented in patient’s medical record. The patient and family do not attend the case conference.

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1.6 PRS clinicians complete patient-specific education and weekly collaborative case conferences for each inpatient with planned receiving team, in the time frame established in 1.4.

Clinicians from the PRS meet with and provide education to the local therapy team in the three weeks prior to the planned discharge (for patients going home), or planned transfer, (for those being transferred as an inpatient). This includes case discussion and education specific to the patient being transferred or discharged.

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1.7 Criteria for discharge of inpatients from the PRS is based upon patient goal attainment. Any transfer of inpatients to LHDs considers local resource capacity and achievable therapy provision.

Once contact has been made (as per 1.4) the PRS and LHD teams work together to determine criteria for when a patient can be transferred from the PRS to an LHD. Teams consider skills, capacity and patient goal attainment when determining the criteria. Once criteria is determined, it is documented and shared with both teams.

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Jack’s story

Jack is currently received inpatient rehabilitation at PRS-Westmead. Following initial discussions, (minimum standard 1.4) it is determined that the following steps must be complete before Jack can return to have rehab locally:

  • Jack can walk up one step with help from mum
  • PRS provide education and strategies to local team about managing Jack’s challenging behaviours
  • Jack only requires physio and occupational therapy three days per week.

These steps are documented and shared between the PRS and local team to ensure understanding.

1.8 PRS inpatient discharge summaries are provided to parent/carer on day of discharge, with copies provided to the patient’s GP and paediatric services at the patient’s local level 4 or 5 paediatric medicine service.

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1.9 PRS outpatient clinic letters are provided to parent/carer within two weeks of the appointment, with copies provided to the patient’s GP and paediatric services at patient’s local level 4 or 5 paediatric medicine service.

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2. Virtual care and electronic medical records

2.1 Where requested by the family or care team, the PRS offer virtual care appointments, where clinically appropriate.

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Mia’s story

Mia is due for a PRS rehab clinic appointment, her dad would like to attend via virtual care. The PRS agree that it is clinically appropriate to do this and provide the family with the MyVirtualCare details.

2.2 For all PRS outpatient appointments, it is recommended that families extend the invitation to their local care team. This attendance can be face to face or via virtual care. Ensure the family is aware of any requirements related to National Disability Insurance Scheme (NDIS) therapists’ attendance, such as funding.

For all outpatient appointments, the family are strongly encouraged to extend the invitation to attend the appointment to their local care team. The local care team members can attend the appointment either in person or virtually.

The family understand that if NDIS therapists attend this may require using their NDIS funding.

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2.3 All medical records, including documentation from outpatients and community health, are added to the person’s electronic medical record within the LHD or Specialty Health Network (SHN)

Ayah’s story

Ayah sees a physio at her local community health centre and her paediatrician at the hospital. Documentation from both her physio and paediatrician are on the LHD electronic medical record, and therefore accessible to both clinicians.

3. Care across the continuum

3.1 Each PRS site provides quarterly outreach clinics in conjunction with LHD services and teams.

Each PRS facility provide at least four outreach clinics each year to locations within their Children’s Healthcare Network. The PRS work with LHDs, who provide the location and/or clinical space. The PRS invite LHD clinicians to attend the clinic for continuity of care and educational purposes.

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3.2 The PRS provide networked support, clinical advice and professional development support to level 4 and 5 paediatric medicine services.

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3.3 Local school teacher and/or principal are included in education sessions and handover of the patient during transition from inpatients to outpatients, or at another appropriate point.

When a child is being discharged from an inpatient rehabilitation program to the outpatient setting, their local school teacher and/or principal are involved in education and handover of requirements for the child to return to school (if this is the appropriate time for the individual child). The clinical team may decide that an alternative time is more suitable, on a case-by-case basis.

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Dae’s story

Dae is currently receiving inpatient rehab. In two weeks, he will be returning home with a graded return to school. His school principal is contacted prior to his discharge from inpatients and is provided with information about Dae’s needs and abilities, appropriate to the school environment. His outpatient team also contacts his schoolteacher as Dae readies to return to school, with any further updates.

3.4 The PRS start the process of transition to adult rehabilitation services, with appropriate children, from 14 years of age.

Any child who attends PRS clinics and has long term rehabilitation needs, has the process of transition to adult services started at their first appointment after their 14th birthday. The initial stages may include discussion about:

  • the process of transition
  • what to expect in the coming years
  • timeframe for when referral to adult services may be made.

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Emma’s story

Emma has recently turned 14 and has a spinal cord injury. At her next outpatient clinic appointment at PRS Newcastle, her doctor will talk to Emma about the process of transition to adult services. Her doctor will explain what to expect in the coming years, including the plan to refer her to an adult rehab service.

3.5 Information about appropriate adult rehabilitation services is documented and provided to families during the transition to adult services.

PRS have documented information about adult rehabilitation services in the patient’s record. This information is provided to young people and their families when they attend appointments during the transition period (14-18 years old).

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Emma’s story

Emma is 14 years old and is provided with information about which service she will be referred to when she transitions to adult services. This is documented in her clinic letter.

3.6 Level 4 and 5 paediatric medicine services provide and facilitate access to equipment required by children and young people currently who are under their care for rehabilitation (inpatients and outpatients).

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Ahmed’s story

Ahmed is attending his local hospital for rehab. He needs a hoist to transfer and disabled toilet with rail for toileting. His local hospital provides a hoist and access to an appropriate bathroom. When Ahmed’s strength and function have improved, he can start walking short distances. He needs a walking frame. His local hospital doesn’t have an appropriate one, but can source one from a local equipment company. His local team support the family to loan the walking frame from the company.

LHD requirements to support coordination of NSW Paediatric Rehabilitation

This is a list of requirements to support coordinated delivery of paediatric rehabilitation in level 4 and 5 paediatric medicine services:

  • On-site allied health professionals, with specific paediatric caseload. These include but are not limited to occupational therapists, physiotherapists, speech pathologists, dietitians and social workers.1
  • Access to child life therapy or resources.1
  • Appropriate treatment space for allied health disciplines, which is wheelchair accessible and co-located with accessible toilet facilities.2
  • Age-appropriate therapy tools and toys.

References

  1. NSW Ministry of Health. Guide to the Role Delineation of Clinical Services (2021). 5th ed. Sydney: NSW Ministry of Health; 2021.
  2. Australasian Health Infrastructure Alliance. Australasian Health Facility Guidelines [Internet]. AusHFG; 2016 [Updated 2016 March 1; cited 2022 September 8].
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