The Ambulatory Care Coordination (ACC) Program, launched August 2007, is designed to improve care coordination through prospective integrated health care planning, 24 hour telephone support and strengthening of partnerships between tertiary and community services for those children with chronic conditions who frequently attend ED or remain in hospital for lengthy periods of time.

Benefits of care coordination reported in the literature include:

• increased patient wellbeing and satisfaction
• improved health outcomes
• enhanced integration with community services
• reduced demand on hospital services

The ACC model of care allows flexibility in tailoring the Program to move along a continuum of care coordination and case management according to the complexity of care needs and intensity of interventions required for individual families.

As self-management is a vital component in any effective chronic disease management model, the Flinders chronic disease self management model underpins the ACC Program to proactively empower families and optimise their ability in managing the impact of their child’s condition and health care needs. It has the added benefit of aligning with the WA adult models of chronic disease management which can only assist in the often difficult transition of many of these children to adult services.

This Program was as an outcome of the SA HealthPlus coordinated trial who observed that the provision of coordination was based not on severity and complexity of a patient’s condition but whether they were good self managers or not (Battersby et al 2005).

The Flinders program provides a generic set of tools and processes that enables clinicians and clients to undertake a structured process that allows for assessment of self-management behaviours, collaborative identification of problems, and goal setting leading to the development of individualised care plans.

The tools include the Partners in Health Scale, Cue and Response Interview, and Problem and Goals assessment (Flinders Human Behaviour and Health Research Unit 2006).

Chronic Disease Group

Unlike adult chronic disease programs that target populations with specific common diagnostic groups such as chronic lung disease, cardiac failure and diabetes, it is much more difficult to define the population in children. The 'generic framework' was utilised to define a chronic condition as a biological, psychological or cognitive disorder that lasts longer than 12 months and results in either functional limitations or increased reliance on services (McPherson et al 1998). The children identified were often under the care of various hospital specialty departments and community professionals.

Eligibility

Eligibility criteria for the ACC Program includes those children with a chronic condition (according the generic framework) and frequently utilise the hospital services i.e.: 4 or more ED presentations, or, more than 2 hospital admissions, or, longer length of inpatient stay than 14 days within the past year, or in the case of infants, is at risk of significant future hospital utilization.

Families who currently receive formalised care coordination from their specialty team are excluded to avoid duplicity of interventions, and ensure cost effectiveness and sustainability of the ACC Program.

Nursing Team

The ACC nursing team consists of experienced acute care and community nurses (total 2FTE) who have undergone education and training in chronic disease management. The ACC nurses take responsibility for continuing liaison with hospital staff and community personnel and complete and update the integrated health care plan (IHCP).

The IHCP is a personalised comprehensive summary of the patients' care, treatment and management and forms the basis for future care planning and goal setting. The roles of each health care professional are clarified to ensure there is no duplication of service delivery and the Hospital Liaison GP liaises with the child's GP. The underlying principle of care is proactive; meaningful interventions are tailored according to individual needs ensuring timeframes are identified.

Parents are a copy of the IHCP and are encouraged to utilize the 24 hour ACC telephone contact provided.

Program Evaluation

The self-management chronic disease model is supported in adult populations targeting chronic conditions such as COPD, heart failure and diabetes and has demonstrated improvements in health outcomes and behaviours, physiological wellbeing and reductions in unplanned health service utilisation and subsequent cost savings (Battersby et al 2003).

However there is a paucity of research concerning care coordination or case management models of care for children with generic chronic conditions (Newacheck et al 1996) and no data has been reported to date where the self management model of care has been applied and validated for the paediatric population.

Therefore a research study is underway to address critical questions that must be answered to provide a comprehensive understanding of the effects of the ACC Program and self management model of care for children with a chronic condition.

The research study is designed to test hypotheses concerning the effects of the ACC Program and self management model of care:

1. The chronic disease self management model can be applied to parents of children with chronic conditions.
2. The ACC Program will provide economic benefit to the health service by reduction in hospital admissions and emergency department presentations and reduced hospital bed days.
3. The Partner in Health scale is a valid and reliable tool to measure self-management of parents of a child with a chronic condition.

In addition to an immediate return on investment with reduced hospital utilisation, if demonstrated to be effective this model of care can be rolled out to other specialties.

 Ambulatory Care Coordination Program (ACC) for children with chronic conditions, (76KB), Child and Adolescent Health Service, Princess Margaret Hospital, 2007.
Program summary information brochure for parents.

 Integrated Health Care Plan, (156KB), Child and Adolescent Health Service, Princess Margaret Hospital, 2007.
Template for recording a patient's integrated health care plan.

Nursing Director, Ambulatory Care, Paediatric Medicine Clinical Care Unit
Princess Margaret Hospital, Perth, WA
Phone: 08 9340 7816

• Battersby MW and the SA HealthPlus Team.  Health reform through coordinated care:  SA HealthPlus.  BMJ 2005; 330: 662-665.
• Battersby MW, Ask A, Reece MM, Markwick MJ and Collins JP.  The partners in health scale:  The development and psychometric properties of a generic assessment scale for chronic condition self-management.  Australian Journal of Primary Health 2003; 9: 41-52.
• Flinders Human Behaviour and Health Research Unit.  The ‘Flinders Model’ of chronic condition self-management.  Flinders University CSSM June 2006.
• McPherson M, Arango P, Fox H, Lauver C, McManus M, Newacheck PW, Perrin JM, Shonkoff JP, Strickland B.  A new definition of children with special health care needs.  Pediatrics 1998; 102: 137.
• Newacheck PW, Stein REK, Klein Walker D, Gortmaker SL, Kuhlthau K and Perrin JM.  Monitoring and Evaluating Managed Care for Children With Chronic Illness and Disabilities.  Pediatrics 1996; 98(5): 952 – 958.