National Clinical Assessment Framework for Children and Young People in Out-of-Home Care (OOHC) - March 2011

3 Coordination and continuity of care

Page last updated: 05 December 2011

Children and young people in OOHC receive inadequate health care due, in part, to placement instability combined with limited coordination and information-sharing between service providers.18

The completion of the Comprehensive Health and Developmental Assessment will clearly define the health needs of children and young people in OOHC and identify the further treatment or interventions necessary to address these. However, for the Framework to be implemented successfully there needs to be effective communication and information sharing between all parties.

3.1 Coordination of care

Complementary, systematic planning and active coordination amongst the following key parties is required to ensure that children and young people in OOHC receive the specific assessments or treatments that have been identified:
  • Child Protection Agency Case Worker
  • Care Coordinator (Health)
  • Carer
  • Child or young person
Where appropriate, the school principal and teachers should also be included in the information flow.

The Framework recognises that responsibility for the care of children and young people in OOHC is achieved via a number of different models each with varying and often complex interactions between jurisdictional child protection, health and education systems.

Each jurisdiction should give consideration to the preparation of effective care pathways to outline how the implementation of the Framework could best be coordinated during a child’s journey. The pathway should outline:
  • the roles and responsibilities of key parties (including the child, the carer, the Health Authority and Child Protection Agency)
  • the information flows associated with each step.

3.2 Development of a Health Management Plan

The key component to facilitate coordination and continuity of care is the development of a Health Management Plan. Under the Framework, it is recommended that each Jurisdiction work to develop for each child a Health Management Plan and for this to be a required element of the overall care plan for each child and young person in OOHC.

Upon entry into OOHC, and preferably before the Preliminary Health Check but certainly prior to the Comprehensive Health and Developmental Assessment being completed, all relevant health information should be consolidated and provided to the practitioner undertaking the assessment .19 This may include information held:
  • by the relevant Child Protection Agency including the child’s personal history and family history if it is known
  • by a school nurse
  • by dental services
  • by community health services
  • by a GP or local hospital (e.g. Accident and Emergency Departments)
  • on any child-held or parent/carer-held record
  • by a paediatrician
  • in the Australian Childhood Immunisation Register (or other immunisation registers)
  • by child and adolescent mental health services.
This information should be supplemented with the timing and outcome of all assessments completed to date, copies of any referrals made and the timing and outcome of those specific assessments (including the results of any tests, schedules of medication or ongoing interventions).

This will essentially establish a comprehensive health record that documents the child or young person’s state of health and identified health needs. This health record, together with relevant referrals and a schedule of future assessments or treatment will constitute the necessary Heath Management Plan.

Initially this should be incorporated into a paper based personal health record which is completed by each practitioner and carried by the child or carer.20 Eventually, it is proposed that the health record would be incorporated into an electronic health record.

This record should be updated regularly, and move with the child. Carers (and where appropriate the child or young person) should also have access to the health record to ensure effective coordination.

The Framework recognises that implementation will be dependent on jurisdictional practice and obligations under privacy legislation. Guidelines for the appropriate information collection, storage, use and disclosure of information may need to be amended. Ideally, this will allow de-identified data to be extracted to contribute to national data collections and to be used in longitudinal research projects to build the OOHC population evidence base.

18 Gluckman, Stephanie and Shaw, Terri (2009) Improving Health Outcomes for Children in Foster Care: The Role of Electronic Record Systems – The Children’s Partnership
19 Hill CM, (2003) Statutory Health Assessments for looked-after children: what do they achieve? Care, Health and Development; 29(1):3-13
20 Effective examples of such records have been implemented in a number of jurisdictions – one such example is the ‘Blue Book’ used extensively in New South Wales.