Altman Lisa, Breen Christie, Ging Joanne, Burrett Sara, Hoffmann Tim, Dickins Emma, Brown Kristen, Zurynski Yvonne, Woolfenden Susan
Sydney Children's Hospitals Network, AU.
Murrumbidgee Local Health District, AU.
Int J Integr Care. 2018 Sep 5;18(3):14. doi: 10.5334/ijic.3953.
Children with medical complexity (CMC) require highly specialised care, often from multiple providers and over many years. This paper describes the first 18 months of development of the Kids Guided Personalised Services (GPS) Integrated Care Program (the Program). This Program aims to improve health care experience; communication and to streamline provision of care.
Key enablers across the Program were put in place and 5 individual project streams were used to implement change. An extensive formative evaluation process was undertaken to truly understand all perspectives in developing the Program.
CONCLUSION/KEY LESSONS: This Program supports families who are caring for CMC by developing shared care models that bring together local health services with the tertiary hospitals. The methodology used has resulted in comprehensive system change and transformation; reduced presentations to the Emergency Department (ED), avoidable admissions and travel time. A challenge remains in meaningfully engaging primary health care providers.
患有复杂疾病的儿童（CMC）需要高度专业化的护理，通常需要多个医疗服务提供者多年的照护。本文描述了儿童个性化引导服务（GPS）综合护理项目（该项目）最初18个月的发展情况。该项目旨在改善医疗体验、沟通并简化护理服务的提供。
该项目的关键推动因素已落实到位，并通过5个独立的项目流来实施变革。开展了广泛的形成性评估过程，以真正了解项目开发中的所有观点。
结论/关键经验教训：该项目通过开发共享护理模式来支持照顾患有复杂疾病儿童的家庭，该模式将当地医疗服务与三级医院整合在一起。所采用的方法带来了全面的系统变革和转型；减少了急诊就诊、避免了不必要的住院和缩短了出行时间。在切实让初级医疗服务提供者参与方面仍存在挑战。
