lessons from the kaleidoscope out of home care clinic

© Hunter New England Area Health Service 2005. All rights reserved. 1

What have we learned from 222 child health assessments of children in out of home care?

Dr Anne Piper, PaediatricianMargaret Ryan, Clinical Nurse SpecialistElisha Stanton, Psychologist

Lessons from the Kaleidoscope

Out Of Home Care Clinic


Kaleidoscope OOHC clinic

Commenced as a pilot in Newcastle 2005.

Initial referrals accepted from one Community Service Centre and Newcastle Centacare.

Later referrals accepted from 3 Newcastle CSCs

Referrals only from Community Services- and criteria that they had not had a recent paediatric assessment and do not have a regular Paediatrician

Initial staffing Paediatrician and Paediatric nurse

Staffing mostly Paediatrician only- 2007 until late 2009.


Kaleidoscope OOHC clinic

Pilot phase:

First 2 years (June 2005 – July 2007) of the Clinic, 55 children seen

Majority of referrals are non-kinship carer placements – 84%

- 13% kinship carers

- 3% natural parent (children under PR of Minister but with a parent)

Average age of children: 7.7 years old

Average time in care: 3.5 years

Average number of placements: >5

Greatest number of recommendations: behavioural concerns


Changes to the OOHC ClinicClinic staffing increased:

In August 2009, Child Protection team psychologist

Child Protection Clinical Nurse role expanded

More comprehensive screening of behaviour and development included in reports

Paediatric Registrar allocated to clinic

Clinic changes organised through existing funding


Process growth:

Multidisciplinary approach to screening:– Psychologist, Nurse and Paediatrician screening in the one assessment

Pathways established - prioritised referrals for:– Speech and language (Speech Pathology)

– Dental

Normal wait times for OT and Physio and any other referrals

Growth of the OOHC Clinic


Evolution of the clinic 222 children seen since 2005

Initial operational issues with inappropriate referrals

Many children in care for many years with kinship carers and already well linked into services.

Intake criteria stricter, if basically unchanged

Referrals screened closely by a clinician after initial few months

Approximately 50 referrals rejected since 2005

Clinic unable to offer follow-up due to excessive demand (estimate 1000 children in OOHC in greater Newcastle)


Past and Present ComparisonsPast Present

55 children seen (2005 – 2007) 54 children seen (Feb – Sept 2010)

Average Age

7.7 years old 5.7 years old

Age Range

2 months to 14 years 11 months 5 months to 15 years 0 months

Average Time in Care

3 years 6 months 6 months

© Hunter New England Area Health Service 2005. All rights reserved.

Past and Present Comparisons

Presenting Issues and Concerns

PAST* PRESENT*

60% behaviour issues 48%

34% speech/language concerns 35%

25% educational issues 16%

25% dental 18%

23% hearing 16%

16% motor 12%

21% vision 11%

*Of the PAST concerns,

only 38% referred on to

other services

*Of the PRESENT concerns,

62% referred on for other

services


The clinic does not aim to replicate services that are already in place or to take over the ongoing care of children already linked into services or medical care

If children are being referred to Kaleidoscope for a specific reason or service- it is not appropriate to divert those referrals to the out of home care clinic

Criteria

Child has recently been placed in care < 12 months

The child does not have a regular paediatrician nor has had a paediatric medical assessment in the last 12 months

The child must be under the parental responsibility of the Minister

The child is aged 0-12 years (occasional referrals of older children will be considered)

The child is not in kinship care (occasional referrals may be considered after discussion)

Referral criteria for the clinic


Kinship careInitially excluded- unless the relative did not have a prior relationship with the

child.

Increasing numbers being referred to the clinic

2010 27/54- 50%

2009 18/55- 33%

2008 14/40 – 35%

2007 8/31- 26% (one living with natural father)

2006- 0

2005 7/17- 41% (2 with natural parents)


Present clinic Processes and Resources Multidisciplinary screening:

– Minimum Paediatrician or Paediatric Registrar, with Psych & Nurse– Health assessment and examination– Clinical interview and Structured play

Minimum 60 minutes per child

Pre- assessment:– Intake processes– Information gathering

Post- assessment:– Report writing, Referral letters / calls– Feedback to Community Services and recommendations re follow-up

Total time cost: Minimum 4 hours per child required


GP involvement GP referral now requested- as no ongoing review offered in

clinic and unable to take over day-to-day medical care.

Allows Medicare billing by Paediatrician, and letter to be sent to the GP

Advised that if further Paediatric review required- should be arranged by the GP to the appropriate service/clinician

Paediatric review to be based on clinical need- rather than to ‘complete forms


Comprehensive ‘one-stop shop’ vs priority pathways (our model)

One day multidisciplinary comprehensive assessment- means all assessments completed on one day- and fewer appointments to attend

But appointments too long for most children and families- can affect quality of the assessment.

Not all children need allied health (SP/OT/Physio) assessment- not an efficient use of staff time.

Not all require developmental assessments- many in past carried out by Community Services psychologists following appointment

Generally Paediatrician clinical assessment adequate for developmental assessments of under 2s.


Lack of clarity re responsibility for coordinating further referrals- caseworker (Community Services) vs caseworker (NGO) vs carer vs health staff

Report not provided to carer by clinic staff- expectation that Community Services do this is as appropriate.

Changes in caseworkers and placements- or no allocated caseworker and lack of follow through of recommendations

Not all medical or background information provided to clinic staff at time of referral

Confidentiality and consent issues

Poor communication between health, caseworkers, carers and natural parents

Lessons learnt


Lessons learnt (ctd)

High turnover of staff in community services and lack of awareness of clinic process and criteria

Regular visits/communication with Community Services offices required to keep referrals ‘on track’

Inability to offer follow-up appointments after the early phase, due to capacity of the clinic

Difficulty of where children can be seen for follow-up if required

Most diverted to Dr Piper’s General Paed or developmental clinic in other services

Not a long term option


Final lessons from our clinic comprehensive health screening early in the placement revealed greater

number of health needs, however many of the children’s needs were not medical.

Referral process very difficult to keep on track

Referrals need to be screened closely by staff with clinical knowledge

GP referral- good baseline screening- if they are provided with adequate information – Most referrals stated “thank you for seeing X for a Paediatric assessment at

the request of DoCS”

Identified developmental and mental health/behavioural needs cannot be met by a purely medical model- nor addressed by a single assessment.


Final lesson learnt Present recommendations are for comprehensive multisciplinary

assessments, however not all children require multidisciplinary approach (eg Speech/OT/Physio)

‘One Stop Shop’ approach may lead to improved compliance – however the length of the clinic may become stressful for the child and carer.

Potential important role of the paediatric nurse:

– Clinic coordination

– General health screen

– Case management and coordination

lessons from the kaleidoscope out of home care clinic

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