The support provided by the Complex Care Hub falls into one of the following services based on the anticipated duration and level of support required by individual patients and families.

Complex Care

• Complex Care is a model of care to support our chronic and most complex medical patients. There are 3 tiers of support with varying intensity that are responsive and flexible to patient and family needs
• Tier 3 support
• A dedicated Registered Nurse as a primary point of contact for non-acute clinical queries
• A dedicated telephone number for administrative support and triage
  
• Tier 2 support, in addition to Tier 3 support
• Allocated a dedicated Clinical Nurse Consultant, Medical Case Manager and Social Worker
• Access to Allied Health input as required
• Tier 1 support, in addition to Tier 2 & 3 support
• In home health care support
• Funding for equipment and consumable as allocated
• Each patient will have a key point of contact, either a Registered Nurse or Clinical Nurse Consultant, to improve communication, coordination and continuity of care from acute to ambulatory
• Integration with community based services to partner with families and community providers to deliver the best care as close to home as possible
• Patient and family advocacy within RCH and the Community
• Promote health independence through individualised patient care plans, goal setting, supporting growth of patient and family self-management skills and capacity

Post Acute Care

• The Post Acute Care (PAC) program provides short-term (up to 4 weeks) support at home to children whose healthcare needs have increased following an acute hospital admission or Emergency department presentation. The program aims to help your child recover at home and prevent readmission to hospital.
• PAC services are offered statewide as long as the patient's admission or ED presentation was to RCH. The services may be provided by RCH staff members or external community organisations. External community based organisations will be used for patients and families who live in a rural area or if PAC staff do not specialise in the type of services required
• View the PAC Brochure for parents and carers

Homecare Program

• The Homecare Program enables children and adolescents with ongoing interventional medical care needs to be safely cared for in their own environment
• The Complex Care Hub nursing team, in consultation with the child parents and doctor, provide child specific training for support workers to provide a defined level of care in the home
• In home support workers are employed by an external community agency and trained for each patient’s requirements by the CCH team

Schoolcare Program

• The Schoolcare Program (SCP) is a state-wide service provided by the Department of Education and Training (DET) in partnership with RCH Complex Care Hub (CCH)
• The CCH team arrange support for children/adolescents who would not be able to attend school without specific medical interventions being performed during the school day
• School support staff selected by the school to be carers for the child/adolescent are provided child-specific training, monitoring and support by the CCH team
• Varying levels of support are offered to children/adolescents at school, based on their independence and/or frequency of interventions
  • Level 1: for children/adolescents who need low level support or supervision for intermittent medical intervention
  • Level 2: for children/adolescents who are dependent on other to complete regular medical interventions
• Further information Department of Education Schoolcare Program

Complex Asthma Service

• The Complex Asthma service offers a multidisciplinary approach to support children and families living with complex asthma

• The service provides:

  • Medical assessment in the Complex Asthma clinic

  • Asthma education and support specific for each family

  • Self-management guidance and support

  • Ongoing nurse care coordination (in consultation with the treating medical team) as required

Post Intervention Therapy (PIT) Funding

• Post Intervention Therapy (PIT) funding is a brokerage fund available to provide additional physiotherapy services for children/adolescents with cerebral palsy (CP) following orthopaedic surgery. PIT funding allows physiotherapists (usually their regular community physiotherapist) to work more closely with the child to assist in achieving the goals of the surgery in the post-acute period. The goals should be decided in collaboration with the surgeon, physiotherapist, the family and the child. PIT should not be used for ongoing management and monitoring, only for direct physiotherapy related to orthopaedic surgical intervention.
• The PIT funding scheme is administered by the Complex Care Hub at the Royal Children’s Hospital, but day to day liaison with community physiotherapists is via the PIT coordinator in the Physiotherapy Department of RCH.
• Forms and Documents
  • PIT Family Info Flyer (July 2018)
  • PIT service provider info pack (July 2018)
  • PIT Application Form (May 2020)
  • PIT External provider - Service Record (July 2018)
  • PIT Exit Summary and Plan (July 2018)
  • PIT Extension of Funds (July 2018)