Continuity of Care in Tertiary Paediatric Rehabilitation: Implications for Social Work Practice

Introduction: Paediatric rehabilitation medicine is an area of subspecialty health care for children, young people and their families who, as a result of injury, medical illness or surgical intervention have functional impairment. Interdisciplinary therapy programs aim to be developmentally appropriate, goal oriented, family-centred and time limited with an overall philosophy to optimise health and function and maximise quality of life, independence and participation in all settings. QPRS provides discrete, sub-acute services, which are separate and distinct from the general ‘rehabilitation’ element of the continuum of care. Services are delivered across the continuum of care in a variety of settings which includes: a dedicated inpatient rehabilitation unit, a Day Rehabilitation Program (same day rehabilitation admission) and a State wide outpatient service. The paper aims to highlight a dilemma in the provision of equitable access to psychosocial services within a tertiary hospital setting in a sub-acute department that supports children until they transition to adult services. QPRS social workers are often drawn into acute occasions of service diluting the availability of staff to provide the psychosocial care that meets the needs of the QPRS population. This tension distracts from the core business of providing a service that addresses chronic sorrow, grief, loss, and adjustment to a life altering diagnosis within the scope of practice of tertiary paediatric rehabilitation. Proposed Practice Change: We will offer an analysis of the evidence surrounding concepts of relational, information and management continuity and provide a rationale for a shift in what it means to provide an integrated service in a tertiary health setting. The content and issues within these categories of continuity of care are critical to QPRS and need to be understood in this specific health care context, if issues of fragmentation are to be addressed and patient care enhanced. [1] Through the use of a case study, we will explore the limitations of a relational continuity model and propose an innovative practice change that we believe is both sustainable and transferable across practice settings where intra-agency communication and liaison is required. [2] Population and Stakeholders: The proposed practice change will directly impact children, young people and families who are known to QPRS and at least one other medical team within Children’s Health Queensland. The proposed practice change will impact the QPRS social work team and social workers providing psychosocial services to children, young people and families engaged in an acute occasion of service within a the hospital setting. Highlights: Participants are encouraged to explore and analyse how concepts of relational, information and management continuity impact their organisation specifically and consider practice changes based on this discussion. Enhanced service provision for QPRS families and the wider CHQ patient population as social work intervention is targeted to align with reason for admission. Discussions: In order to provide sustainable and integrated health care, clinicians must promote relationships with the agency as a whole, rather than focusing exclusively on the patient-clinician relationship. Continuity of care can be achieved when clinicians prioritise good clinical handover and communication.