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Scaling paediatric integrated care for chronic and medically complex children living in rural New South Wales, Australia


Emma Dickins

Sydney Children's Hospitals Network, AU
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In 2015, the Sydney Children’s Hospitals Network (SCHN) implemented an integrated model of care for children in metropolitan Sydney that helped to: reduce presentations to Emergency Department (ED) by 40%; reduce day-only admissions to tertiary hospital by 42%; and improve the quality of care for paediatric patients . Given these successes, further work sought to effectively adapt, scale and spread this child-centred model of care across rural and remote New South Wales (NSW).


To scale paediatric integrated care models to rural and remote NSW

Targeted population and stakeholders

This work targeted health districts outside of Sydney, with the southern part of NSW (SNSW) emerging as a key area for spread. In 2018, 700 children from SNSW attended over 2000 appointments at SCHN, with 200 of these children attending more than 4 appointments on average throughout the year. 


July 2018 - ongoing


By adapting existing integrated care systems, co-designed with rural and remote stakeholders, a shared care model between SCHN and the rural health district was established. Keys to the successful spread of this model included;

Co-design and collaborate on patient centred-model of care

Early and frequent design workshops with multidisciplinary and multigeographical representatives. Site visits and video conferences for key stakeholders to foster shared understanding of both a) experiences of staff counterparts and b) experiences of rural children with medical complexity (CMC).

Appropriate resources

The child-centred model is enabled by coordinators who work closely with all members of the care team and family to meet the child’s needs. Dedicated rural paediatric care coordinator(s) at the site of spread is necessary for successful implementation amongst rural regions.

Clearly define operational detail

Smooth implementation of the model requires consideration of operational detail, including;

-           Clear lines of communication, workflow and referral

-           Description of roles and responsibilities of the rural CC, and how this role interacts with existing metropolitan CCs

-           Development of shared care plan templates to improve communication and support decision-making

Promote and encourage local capacity

Support local capacity to provide safe, accessible, timely, sustainable and improved quality of care.

Impact and Outcomes

This piece of work demonstrated the feasibility of adapting an integrated care model to optimise access to local care for children with complex health needs in rural and remote areas. The formal evaluation of this project will produce a strong business case and implementation plan to enable a rolling spread of this model throughout other rural and remote health districts in NSW.

Sustainability and Transferability

There are opportunities to progress existing initiatives, extend into new clinical or geographical areas, and consider broader paediatric populations.


A child-centred integrated care model can be spread and scaled across rural and remote areas of NSW.

Lessons learned

Embedding referral criteria, model of care guidelines, and communication tools into everyday clinical systems supports consistency and reduces variability in practice. 

How to Cite: Dickins E. Scaling paediatric integrated care for chronic and medically complex children living in rural New South Wales, Australia. International Journal of Integrated Care. 2021;21(S1):148. DOI:
Published on 01 Sep 2021.


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