1. © Hunter New England Area Health Service 2005. All rights reserved. 0 What have we learned from 222 child health assessments of children in out of home care? Dr Anne Piper, Paediatrician Margaret Ryan, Clinical Nurse Specialist Elisha Stanton, Psychologist Lessons from the Kaleidoscope Out Of Home Care Clinic

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

3. © Hunter New England Area Health Service 2005. All rights reserved. 2 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

4. © Hunter New England Area Health Service 2005. All rights reserved. 3 Changes to the OOHC Clinic Clinic 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

5. © Hunter New England Area Health Service 2005. All rights reserved. 4 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

6. © Hunter New England Area Health Service 2005. All rights reserved. 5 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)

7. © Hunter New England Area Health Service 2005. All rights reserved. 6 Past and Present Comparisons Past Present 55 children seen (2005 – 2007)54 children seen (Feb – Sept 2010) Average Age 7.7 years old5.7 years old Age Range 2 months to 14 years 11 months5 months to 15 years 0 months Average Time in Care 3 years 6 months6 months

8. © Hunter New England Area Health Service 2005. All rights reserved. Past and Present Comparisons Presenting Issues and Concerns PAST*PRESENT* 60%behaviour issues48% 34%speech/language concerns35% 25%educational issues16% 25%dental18% 23%hearing16% motor12% 21%vision11% *Of the PAST concerns, only 38% referred on to other services *Of the PRESENT concerns, 62% referred on for other services

9. © Hunter New England Area Health Service 2005. All rights reserved. 8 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

10. © Hunter New England Area Health Service 2005. All rights reserved. Kinship care Initially 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)

11. © Hunter New England Area Health Service 2005. All rights reserved. 10 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

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

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

14. © Hunter New England Area Health Service 2005. All rights reserved. 13  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

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

16. © Hunter New England Area Health Service 2005. All rights reserved. 15 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.

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