Complex Care Hub

Eligibility

  • The eligibility for each of the Complex Care Hub services is outlined as below:

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    Post Acute Care

    Children being discharged from the RCH (including from the emergency department) are eligible for PAC support if their care needs have increased as a result of their admission or ED presentation.

    Post-acute care services provide individually tailored packages of services to patients who have one or a combination of:

    • A short-term need for community nursing intervention such as
    •  A need for a short-term, single discipline allied health intervention
    • A short-term need for community-based supports on the account of the child’s healthcare, psychological needs and home environment
    • The need for services must be linked to their hospital presentation to facilitate a safe and timely discharge

    Schoolcare program

    • Eligibility is granted based on the Schoolcare Program guidelines
    • The Schoolcare Program is available to staff employed in Early Education Programs within some Victorian Government Specialist Schools
    • The Schoolcare Program is not delivered to staff in kindergartens. Depending on the specific needs of a preschool child, a kindergarten may investigate possible support through a Kindergarten Inclusion Support (KIS) package. More information is available at Kindergarten Inclusion Support Packages

    Homecare Program

    The eligibility for the Homecare Program is based on the patient requiring ongoing in home interventional healthcare needs and the ability to self-fund the care requested. The funding source may be Individual Support Packages, National Disability Insurance Scheme, Local Government, TAC, Centrelink payments or other.

    Complex Asthma Service

    Each of the four below criteria must be met to be eligible for the Complex Asthma service.

    (Please note at present only internal referrals can be accepted).

    1. Chronicity

    • Does this child have recurrent episodes of asthma?

    2. Instability

    • Have they had an emergency presentation in the last 12 months?

    3. Functional limitation

    • Does asthma impact on their school attendance or parent absenteeism from work?
    • Do symptoms affect participation in age appropriate activities?

     4. Complexity Any one of the following:

    • Frequent presentations: 5 presentations in 12 months

    • ICU admission in the last 12 months

    • Co-morbidities: e.g. anaphylaxis, cardiac disease, neuro-disability

    • Psychosocial complexity: e.g. isolation, CALD, poor health literacy, parental health concerns, family violence

    Complex Care

    The first 4 of the below criteria must be met to be eligible for Complex Care. Criteria 5 and 6 provide information about the level of support required.

    Eligibility criteria

    1. Chronicity

    This child’s condition is expected to be present for 12 months.

    2. Complexity

    Complex problems are not the same as complicated problems. There are components that interact and are not independent and predicting response and progress may be difficult.
    Diseases may be present in different organ systems that effect each other in unpredictable ways or social factors may impact significantly on health and care provision.

    1. Medical
      Medical complexity is defined as greater than 10 medical appointments in 12 months (actual or in the case of an infant predicted)
      Note: When counting the appointments, do not include:
      • FCP/Complex Care/ACE visits (unless they are drop-in Complex Care appointments in lieu of an A&E visit)
      • Allied health visits
      • Any visits that could be accessed in the community, but were attended in RCH due to convenience.  (eg. Immunisation Centre).
      • In-home appointments (PAC and Wallaby)
    2. Psychosocial
      Social complexity is defined as significant difficulties in areas of carer health, geographical isolation or disability.
      Note: Psychosocial complexity may prevent children from attending all of their scheduled clinic appointments, and may be a barrier to meeting the medical complexity criteria

    3. Instability

    This child has had more than one emergency admission in 12 months.

    Note: this can be actual OR predicted.  Consider the child’s condition or interventional care need and how that could increase the potential for an emergency admission, for example:

    Does this child have an indwelling device that could increase their risk of infection?

    Does this child have a condition that could require sudden unexpected medical attention, such as epilepsy or respiratory vulnerability?

    4. Functional limitation

    This child’s condition impacts on their participation in independent age appropriate activities.

    Note:  For an infant, please think of their potential for functional limitation.

    Does this infant’s condition impact their ability to be cared for by others

    Or does this child’s interventions affect their mobility or ability to undertake activities?

    5. Fragility

    This child has had more than 5 hospital admissions in 12 months or 30 inpatient days in 6 months.

    Note: Wallaby is included for hospital admissions, Bilby, Overnight Accommodation, Day Medical and Day Surgical do not.

    6. Intensity

    This child has an interventional health care need and require a technology or a procedure in their home.

    Examples of interventional health care needs

    • Intensive bathing for EB patients and severe skin conditions
    • TPN
    • Tracheostomy
    • Ventilation (both continuous and overnight)
    • Baclofen  Pump
    • NJT
    • Suctioning when related to a life threatening need, for example complex seizures

    What does not apply?

    • PEG feeds alone
    • Suctioning alone
    • Emergency seizure management; if medication only
    • Presence of a stoma
    • Emergency medication eg. anaphylaxis, asthma

    If your patient meets one of or both of the fragility or intensity criteria then further information on the patient and family needs (Initial Needs Assessment) will be required to understand the level of support that they require. This information will be incorporated in the referral pathway through the EMR and the following guide will assist in providing accurate information.

    Initial Needs Assessment

    Critical care needs

    These needs are scored as follows:

    Low needs

    2

    Moderate needs

    4

    High needs

    6

    Severe needs

    8

    1. Respiratory needs

    • Low: This patient is on regular medications for their respiratory condition. For example, bronchodilators, inhaled antibiotics, saline nebulisers.
    • Moderate: They are using low flow oxygen, they rely on an NPA, need suction for airway clearance or require chest physio or cough assist.
    • High: This child is tracheostomy dependent or requires overnight CPAP or AIRVO.
    • Severe: They are dependent on continuous high flow oxygen, continuous ventilation or require overnight respiratory support and have a very high vulnerability (eg. Central nocturnal hypoventilation)

    2. Nutrition

    • Low: This child requires PEG/NG top-ups and has some oral intake.
    • Moderate: They are reliant on PEG or NG feeds as their sole nutrient and these feeds are tolerated well.
    • High: All nutrition is given via PEJ or NJ tube. Or this patient may have continuous/overnight feeds that are poorly tolerated, requiring a high level of monitoring for risk of vomiting or aspiration.
    • Extreme: This child is dependent on TPN.

    3. Neurological

    • Low: This child has occasional seizures that are well controlled, but require regular medication and some increased supervision for activities.
    • Medium: This child’s seizures require the use of emergency medication to terminate them, and this occurs at least weekly.
    • High: This child experiences seizures which require emergency medication, they occur at least daily during the day or multiple times a week overnight. <
    • Severe: Frequent seizure events occur multiple times in the day or night and require both emergency medication and airway support

    Note: This may also include other life-threatening paroxysmal events.

    4. Skin

    • Low: This child has an identified pressure injury risk as per Glamorgan Scale.
    • Medium: Regular skin treatments are required. This include the use of creams several times per day and the weekly care of a CVAD or tracheostomy (not including management of a port).
    • High: There is a requirement for daily dressings and bathing.
    • Severe: This child suffers from life threatening skin breakdown.

    5. Psychological

    • Low: This child’s reactive anxiety impacts on participation in age appropriate activities or becomes an impediment for delivering care interventions. No specific treatment required is required for this.
    • Medium: This child experiences a mood disorder or cerebral irritability that requires medication or other therapy. Or this patient may have a behaviour management plan in place, which is successful in eliminating harmful behaviours.
    • High: This child displays self-harming behaviours.
    • Severe: This child exhibits high risk behaviours with potential for harm to self or others, including carers.

    Q To adapt psychological factors for children who have developmental disability, please consider the question: How difficult is it for the child to remain content?

    Additional care Needs

    These needs are scored as follows:

    Low needs

    1

    Moderate needs

    2

    High needs

    3

    Severe needs

    4

    Note: scores for additional care needs are only given for impairment which is not expected at their age. For example, no score will be given for communication care or mobility needs for an infant.

    1. Medication

    • Low: This child is prescribed regular routine medications, and this may include PRN non-opioid analgesia.
    • Medium: Medication administration varies with symptoms and may be required overnight.
    • High: Medications are administered via infusion. For example, TPN and ITB pumps. This can also include the administration of PD fluids.
    • Severe: This child experiences severe intractable pain and requires 2 hourly medications or an infusion. This child may also receive a medication via infusion with high risk to the patient if medication delivery is interrupted, for example prostacyclin or an inotrope.

    2. Communication

    • Low: This child needs some support to communicate. For example, speech pathology or voice amplifications devices.
    • Medium: This child uses communication devices or sign to communicate.
    • High: Familiar people can understand the child’s communication to make choices and decisions.
    • Severe: This child’s communication is limited to expressing emotion that familiar people can understand. 

    Could someone who hasn’t met the child understand the child’s communication of their needs?

    Can the child communicate to make a choice? For example, they would like to stop watching TV and listen to music?

    3. Mobility

    • Low: This child’s mobility needs support but they can independently transfer themselves. They may use a mobility aide.
    • Medium: This child requires assistance from one person for transfers.
    • High: This child requires assistance from two people for transfers.
    • Severe: This patient’s mobility and weight requires them to be hoisted for all transfers.

    4. Continence/Renal

    • Low: This child has a stoma, however the management of the stoma is uncomplicated. This child may require assistance with toileting and they are aged 4 years and over.
    • Medium: This child requires regular catheterisation or bowel washouts to maintain continence.
    • High: This child experiences incontinence continuously despite interventions.
    • Severe: This child is dependent on dialysis, peritoneal dialysis or haemodialysis.

    Complexity factors

    These needs are scored in addition to the care needs to capture the family complexity, capacity and care burden.

     

    Low

    High

    Language

    1

    2

    Carer health

    1

    2

    Housing/isolation/availability of alternative carer

    1

    2

    Adverse Life Events

    1

    N/A

    1. Language

    • Low: The family have some difficulty with communication or literacy.
    • High: The family have limited capacity to communicate in English or the parents have very poor ability to make informed decisions on behalf of their child due to an intellectual disability.

    Can the parents advocate and make decisions about the child’s health needs without the assistance of an interpreter?

    Can the parents easily navigate the hospital system and do they have reasonable health literacy for decision making?

    2. Carer physical and mental health

    • Low: A parent or sibling has chronic health concerns requiring regular treatment.
    • High: A parent or sibling has a significant illness. For example, they are undergoing treatment for malignancy

    Note: Please also include an additional score of 1 for a family of 5 or more children under 16 years of age who are residing in the same home.
    Please also include here a score for young parents, less than 20 years of age.

    3. Housing/isolation/availability of alternative carer

    • Low: The family experiences one factor.
    • High: The family experiences multiple factors.

    Examples of appropriate factors:

    • Family of Aboriginal and Torres Strait Islander Heritage.
    • Single Parent
    • Living a significant distance from the hospital
    • Financial difficulties
    • Transport difficulties and social isolation
    • Lack of informal support

    4. Adverse life events for child or family

    Examples include:

    • Recent bereavement
    • Recent trauma to child and family
    • Significant financial hardship
    • Unplanned relocation
    • Recent unemployment
    • Recent significant illness requiring prolonged hospitalisation
    • Significant accident
    • House fire/bushfire /flood