Integrating health systems for children and young people in out of home care: Challenging the nature of siloed service delivery in rural Australia
Abstract
Objective
The purpose of this paper is to report on enablers and barriers during the first 2 years of the health systems integration project that included the implementation of a health navigator role. The project aims to improve health outcomes for children and young people residing in out of home care in rural Australia with a health navigator co-located between child protection practitioners and community health services clinicians.
Setting
Rural Northwest Victoria.
Participants
Sunraysia Community Health Services and the Department of Health and Human Services.
Design
The qualitative design of the project evaluation involved semi-structured interviews and documentary evidence analysis. Analyses of interviews and documentary data demonstrate the challenging nature of siloed service delivery in rural Australia, particularly during a time that comprised multiple interruptions due to COVID-19.
Results
A limited synergy between organisational priorities and reporting systems hindered project progress. The lack of a shared definition of ‘health’ challenged the effective collaboration between health clinicians and child protection practitioners and the role of the health navigator. The health navigator raising health awareness through project involvement, training and sector-wide stakeholder engagement resulted in a slow but steady process of increased prioritisation of health care, increased health literacy among the child protection workforce, and broadening participation of area-based stakeholders, but did not translate to increased access to health plans for children.
Conclusion
Integrating health systems across multiple sites with support of a health navigator revealed difficulties, particularly during COVID-19. The first phase of the project demonstrated the value of shared governance and partnerships as an imperative foundation for fundamental change. Relationships strengthened throughout the project, leading to a better understanding of area-based strengths, which in turn supports improved pathways to health care for children and young people in OOHC within rural communities and driving the subsequent phases of the 10-year project.
What is already known on this subject?
- Timing of health assessments is crucial for children and young people in out-of-home care because they have higher health care needs than the general population.
- There is a need to develop better health pathways for children and young people that involve them in health care planning; children and young people are the experts in their own life.
- Long waiting lists, out-of-pocket expenses, and navigating consent impact on carers and their ability to access health services for children and young people in their care, particularly in a rural context.
What this paper adds?
- Health illiteracy, limitations to understanding health information, and complex health systems impact on collaborative service delivery.
- Co-designing innovative system responses requires long-term sustained commitment across the sector, including adequate resourcing of a health navigator.
- Trust and courage are required to address cultural differences between workforces with shared governance to effect and sustain inter-agency change and common practice.
1 INTRODUCTION
In Australia, children and young people (aged 0–18 years, referred to as children from here on) can be placed in out-of-home care (OOHC) when they are unable to safely remain at home due to child abuse, neglect, or when parents are unable to provide adequate protection.1 OOHC is a significant intervention that can involve foster, kinship or residential care.1 Since 2017, the number of children in OOHC has increased by 7.3%, with higher rates reported in remote areas (14.6 per 1000) compared with major cities (6.7 per 1000). Nationwide, approximately 46 200 children are living in OOHC, 9146 of whom reside in the state of Victoria.1
Children in OOHC typically present with higher physical, mental and developmental health needs compared with their non-OOHC peers,2-4 which is due, in part, to not having access to timely and adequate health care. The health needs of children in OOHC are often not prioritised, which leads to long-term chronic health conditions.3, 5 This is particularly salient in rural and regional communities where health care inequalities remain a significant issue because of reduced access to primary health care services.6, 7 Scarce resources and a demand for health care that exceeds supply in rural Australia for allied health, social work, medical and nursing professionals is problematic.8
The crisis-driven nature of child protection service delivery, with limited stable placement opportunities, poses additional challenges to achieving positive health outcomes for children in OOHC.5, 9, 10 Such limitations are particularly impactful on First Nations children who experience higher rates of removal from their homes and cultures than non-Indigenous children1; reflecting the ongoing impact of colonisation and systemic denial of human rights for this group of people.11 At present, most Aboriginal community-controlled health services do not have sufficient resources to provide the health assessments and services needed for First Nations children in OOHC.12
Several national and state-based policies are tackling the issue of health care for vulnerable children. The 2011 National Clinical Assessment Framework for Children and Young People Out of Home13 was developed to improve the quality of health care for children in OOHC. This framework recommends a preliminary health check within 30 days of a child entering care, followed by a comprehensive assessment at 90 days, and for all children to have a health management plan. However, with no statutory requirement for health assessments in place, there are no processes that ensure the health checks are undertaken and child protection practitioners do not routinely gather health information.14 Victoria's strategic plan for Health Services and Infrastructure Design 2017–203715 prioritises the development of preventative, integrated health systems for vulnerable children in the community. And the Pathways to Support for Children and Families: Priority Setting Plan 2021–2416 is a Victorian state-wide plan that focuses on the most pressing needs of children and families while addressing community self-determination through local governance and shared ownership.
Despite these national and state-wide policies, there is currently no systematic state-wide approach to identify and manage the health needs of children living in OOHC in Victoria. Past initiatives emphasised the importance of service coordination but lacked integrated approaches in line with the National Clinical Assessment Framework.2, 13 The Northern Division of the Department of Families, Fairness and Housing has sought to implement an integrated approach between child protection and clinical health care providers to better support the health of children in OOHC. The project draws on elements of horizontal integration that provide care between health, child protection and other providers using multi-disciplinary teams that support a child in care.17 The purpose of this paper is to share learnings from phase one (2020–2021) of a 10-year project that aims to improve health outcomes for children in OOHC in rural Northwest Victoria (Modified Monash Model 3, 5, and 618). Phase one examines how the existing systems enabled and hindered the integration of health care for children known to child protection who require a health assessment as part of their health care planning.
1.1 Background
In 2017, the Department of Health and Human Services (DHHS) North Division (now known as the Department of Families, Fairness and Housing (DFFH) North Division) set the intention to develop better area-based integrated health systems for children in OOHC. A discussion paper by Webster2 was provided to the DHHS to support and guide how best to implement an area-based integrated health system, and departmental funding provided in 2018 supported initial exploratory work on an area-based service design, which developed the groundwork and framing of the project. The background briefing by Webster2 and a professional development day in 2019 helped with the formation of a clinical advisor group, a project control group, an evaluation framework, and the recruitment of a health navigator. The aim is not to integrate child protection and clinical health care providers completely. Instead, it draws on elements of horizontal integration that provide care between health, child protection service delivery, and other providers using multi-disciplinary teams that support a child in care.17 The 2019 DHHS North Division business case (internal document, not for distribution) guided the overarching project goals: (1) Establish and promote ongoing quality improvement approaches in existing area-based health service design and delivery for children in OOHC, (2) develop new, integrated, sustainable area-based approaches for meeting the health care needs of children in OOHC, and (3) ensure health care for children in OOHC is equitable, efficient and effective.
A dedicated resource operationalising this horizontal integration is the role of a health navigator, providing liaison and information flow between a child, carers, child protection, community services and health providers.19 The role of the health navigator was to (1) collate comprehensive health history for children in OOHC, (2) coordinate referrals to support comprehensive health assessment and individualised health care planning in partnership with child protection practitioners, (3) monitor the implementation of health care plans in partnership with child protection practitioners and to ensure timely access to health care, and (4) liaise between agencies and act as an educational and resource person for frontline child protection staff and caregivers. The initial plan was for the health navigator to be co-located in the child protection team. In early 2020, the rollout of the 10-year project commenced, almost in near synergy with COVID-19, which hindered co-locating the health navigator in the child protection office.
The purpose of this paper is to report on what worked well and less well during the early phase of the health integration project, with a focus on the implementation of the health navigator role.
2 METHODS
This paper details the findings of phase one (2020–2021) of a 10-year project that aims to improve health systems integration, undertaken by the DFFH North Division in collaboration with Sunraysia Community Health Services (SCHS). The qualitative approach involved individual interviews with project members in their natural environment to produce rich, descriptive data and investigating documentary evidence.20, 21 Evaluators attended monthly clinical governance and program control group (PCG) meetings and other relevant (stakeholder) meetings.
The study received ethical approval from La Trobe University Human Ethics Committee (HEC20082).
2.1 Data collection
- Documentary evidence (secondary data set) (Table 1) provided context for the project and detailed information about how the integration of the health navigator developed, including barriers and opportunities as they were discussed during governance meetings and ongoing progress reports.
- Individual interviews (primary data set) with key stakeholders were conducted twice (12 and 20 months from project commencement) to examine the enablers and barriers to the implementation of the integrated health system from various stakeholder perspectives (Table 2). Questions focussed on achievements, challenges, critical touchstones and blockages participants experienced and how these influenced the deliverables of the project. Participants were asked to share changes they observed and (future) implications of health system integration on practice.
| Documents | Year |
|---|---|
| Original business case | 2019 |
| Project control group meetings | 2020–2021 (n = 15) |
| Clinical advisory group meetings | 2020–2021 (n = 12) |
| Stakeholder meeting minutes (Family Support Services, Therapeutic Care Programs, Primary Health Network, Public Hospital, Aboriginal Services, Council, and the Department of Education) | 2021 (n = 1) |
| Progress reports | 2019–2020 (n = 3) |
| Inter-agency referral document | 2020 (n = 1) |
| Plan Do Study Act meetings | 2020–2021 (n = 5) |
| Description | Year of interview |
|---|---|
| Health Navigator SCHS | 2020–2021 |
| Principal Practitioner, Child Protection DHHS | 2020–2021 |
| Project Lead, Community Partnerships DHHS | 2020–2021 |
| Academic Advisor, PCG member | 2020 |
| Compounding Pharmacist, PCG member | 2020–2021 |
| Program Manager, Community Partnerships DHHS | 2020–2021 |
| Executive Manager, Clinical Services SCHS | 2021 |
2.2 Recruitment
Interview participants were purposively sampled. Their selection was based on maximising variability in roles involved in phase one of the project. Participants were approached via email and interviewed individually (Author 1 & Author 6) via video conferencing due to COVID-19 restrictions. Table 2 describes the study participants' vocation and role in the project. Two data collection points provided the experiences and reflections of the participants as the project evolved, identifying barriers, facilitators and opportunities for improvement. Participants contributed voluntarily without compensation, and all interviews were recorded and professionally transcribed with participants' permission. Each interview took approximately 60 min.
2.3 Data analysis
Data analysis followed an iterative process22 undertaken by an experienced qualitative researcher and research assistant (Author 1 & Author 3). NVivo© (QSR International Pty Ltd.) software was used to facilitate the coding and analysis of the data. Analysis was guided by the two pre-established overarching themes of barriers and enablers, and within those the sub-themes of health awareness, health system awareness, health literacy, identifying children and their health status, referral pathways, system access, data recorded on systems, the child protection operating model, sector-wide advocacy, stakeholder engagement and cultural differences between workforces emerged from the primary and secondary data.23-25 Data triangulation was achieved by two research team members (Author 1 & Author 6) reviewing the identified barriers and enablers, confirming relevance across the primary and secondary data sets. The analysis was not based on any pre-existing theory or research, with the primary aim to describe the barriers and enablers of phase one that emerged from within the data sets.
Because qualitative data involve multiple meanings and a degree of interpretation,26 various strategies were employed to ensure the credibility of the analysis.27 Firstly, multiple researchers were involved in the analytic process, which ensured a degree of intersubjectivity. Secondly, member checking occurred with the researchers reporting the findings to some project groups for input. This also included describing the context (i.e. Modified Monash Model, 3,5, and 618), which is essential when considering the transferability of findings to other geographical locations.26 Thirdly, findings were aided by illustrative quotes that exemplified the complexity and challenging nature of system integration. For confidentiality purposes, the quotes are presented without reference to the role of the interviewee within the project.
3 FINDINGS
The objective of phase one of the project was the identification of barriers and enablers for sustainable change that improves health outcomes for children in OOHC, with a focus on the implementation of the health navigator role (DHHS North Division business case 2019, internal communication). Analyses of interviews and documentary data demonstrate the challenging nature of siloed service delivery in rural Australia, particularly during a time that comprised multiple interruptions due to COVID-19.
3.1 Barriers
Child Protection staff want the best outcomes for these kids…but they just do not have the knowledge and understanding of what health wise needs to occur. They think that just by having someone make sure that the child gets to see the paediatrician, the dentist, physio, speech, whatever. Tick, tick, tick, that's fine, they have done what they think is in the best interest of the child.
Sometimes in child protection, we got a child's name, and we need to go out and see what is happening for that child, I do not think that should be a barrier. For a referral to a health service, I think that some of that health information for the referral can be collected along the way …. at present, we might spend 4 weeks in child protection for getting the referral for health services right ….
On multiple occasions, a referral for health services was not actioned because health details were not known to child protection staff. A lack of shared language or terminology between child protection and health systems meant that the information required for a health check was not adequately recorded on the child protection client management system. A mismatch between health and child protection systems was exacerbated by different language/terms and differential focus on the ‘needs of the child.’ The collaborative practice was compromised due to the health referral processes not aligning with the daily reality of child protection staff who often balance competing demands. With a focus on the immediate safety of children needing protection, child protection staff assigned low priority to follow up on what were considered non-urgent health needs. As a result, the project became stuck in-between child protection service delivery, health clinicians' requirements and project objectives.
As time went on and I was waiting, waiting for referrals…. I spent a lot of time going through the child protection history and trying to extract information that was not in chronological order, no dates…. trying to put a story together to fill in their referral form that would go to Sunraysia.
I think the way my – from the health perspective, trying to extract anything, I did not think it would take so long. It is hard to search through 19 pages to get something and put it in, because it is not succinct. I think it was August I sent the first referrals that I had filled in, taken from the client profile, sent them back to the case manager and the team manager…and copied in my contact person, and highlighted all the bits that I needed more information on, with the consent form, and said, can you fill these in and can you get back to me on all the gaps, and I haven't heard back from anyone.
A huge frustration, because it's hard enough to try and find what you need to put into the referral form that's going to go into our patient management system. It's hard enough to get all that. Then, I need to know who their GP is, so that that's the first one that I contact once I have the consent to share information form signed, to get any of their medical history, any diagnosis, things like that, so that I can put that in the Sunraysia system.
Entrenched ideas regularly surfaced around the existing systems and their inability to change or be changed. Consequently, there appeared to be a lack of recourse to collect data from overcoming the system barriers and addressing systemic changes at a decision-making level. The project group agreed that in an ideal model, a child's health record moves with them if they change OOHC arrangements, and health records need to be ‘owned’ by the child and carer. It also highlighted that frontline child protection staff face multiple project demands, staff shortages, and the pandemic, so their commitment to finding health data was not a priority.
3.2 Enablers
…the partnerships are a great achievement…with Sunraysia. I think even [if] it's just for the group… we'll kind of transform things going forward, I think that that's been a real key in partnering with a health service about our children's health.
A stakeholder workshop with representatives from across the sector (i.e. education, council, maternal and child health, counselling services, family support services, hospital and therapeutic care) generated a broader narrative about the health care needs of children in OOHC. The workshop outcomes further developed inter-sectoral partnership exploration and shared responsibility for achieving better health systems integration and outcomes. The development of a clinical paediatric child and family hub born out of SCHS was considered a significant achievement in the second half of phase one. Funding through Murray Primary Health Network to invest and strengthen paediatric service access in the area, with a focus on multi-disciplinary service responses to children, resulted in the recruitment of a paediatrician and the re-distribution of funding to structure a service that found its place in the child and family hub.
…while we haven't had the throughput of data that we probably would have liked to have seen, there's been many engagements that I've seen with child protection, with the health sector… Child protection has come a long way, particularly in the last probably 12 months, to really understand this is important…. there were a dozen child protection practitioners at that education session was significant on what previously would have been possible.
I think one of the things that has stood out for me in this rural site has been, in comparison to other sites, the things that are strengths are that people – professionals are well connected locally. Everyone knows everyone or knows of everyone. That is a strength when they are willing to co-operate, which I have unfailing heard people are willing to co-operate. I'm sure there are tensions between organisations, and there are failures. But as a general impression, I have witnessed in meetings that involve several agencies people coming with genuine intent to the table to say we share a desire to do better in this space.
4 DISCUSSION
Phase one of integrating health systems for children in OOHC in rural Northwest Victoria coincided almost synchronously with the COVID-19 pandemic, hindering typical rapport-building methods and sharing of information. The health navigator could not develop relationships with child protection staff on site, so access to client information systems and information was limited. In retrospect, this impacted project progress more than was anticipated and the findings and outcomes of this project should be considered within the context of the time.
Phase one focussed on the grounding work as suggested in Webster's2 discussion paper and the original DHHS 2019 business case; developing values and accountabilities about health service quality for children from OOHC, establish a common mission to assign governance responsibilities, dedicate resources and develop workforce and data capacities that will support integrated working. Even with Webster's guidelines and recommendations in place, phase one faced some of the same challenges that were raised in the Webster discussion paper.
For example, the findings demonstrate that health illiteracy in child protection service delivery limits health planning for children in OOHC. It is well established that child protection staff have excessive workloads. The Victorian Auditor General's Office28 have said that “unreasonably high workloads are reported at least as far back as 2009” and that “the system struggl[es] to meet its operational responsibilities”. It is therefore reasonable to assume that child protection staff are having to prioritise some aspects of the role over others. While the child protection manual29 mentions the need for the health assessment and the recording and maintenance of health information on the reporting system, much of this information is under the ‘advice and protocols’ section as opposed to the procedure section, which may inherently push it down the list of priorities as child protection practitioners maintain a focus on risk as their core business. As such, in this project's first phase, raising health awareness and increasing health literacy among child protection practitioners became essential to the health system integration for children in OOHC.
Courageous conversations conducted in governance groups, stakeholder meetings and training sessions with child protection staff enabled project participants to reflect on cultural differences between workforces. As important as these conversations are to promote children's ongoing health needs on the ground, we also argue that it needs to be understood within the context of broader child protection systemic issues and stressors that need to be addressed from above.
The health navigator role may go some way to alleviate the abovementioned pressures. If the health navigator had the authority to manage much of this work, then they could relieve some of the burden from the over-worked child protection practitioners. However, cross-sector interoperability of systems also emerged as a critical factor; with adequate resourcing, support, and autonomy of the health navigator role being lacking, and is now viewed as an essential component for phase two's success. Improved health governance and clear leadership roles are also essential for driving systems integration and the project's success. The project became part of the operating environment where there was no authorised environment or ownership for collecting children's health information in OOHC. No one was responsible for advocating for OOHC children's health; therefore, no specific accountability existed for setting and achieving goals. In the future, a more sophisticated systems-level co-design is needed to examine the interoperability of data systems, with health navigators authorised to address these barriers.
The interagency collaboration and structured nature of the project has supported a sense of accountability to the overall project and identified resources, structures and strategies required to fulfil the project's aims. Shared governance models are known to be an effective and dynamic approach that promotes collaboration through the sharing of knowledge, collective decision-making and accountability for practice.30 Findings show that shared governance was essential to create and sustain inter-agency change and common practice for this project and that this is an ongoing process, not something that can be completed in a short timeframe. Co-designing innovative system responses requires long-term sustained commitment across the sector and the members of the Project Control Group discovered this in phase one and have set themselves up well for phase two with further commitment to the shared governance model.
There was evidence of awareness and desire to create changes at both systems and service levels. In particular, the participants note the benefits of breaking silos, working in partnership and having a stronger focus on child and carer engagement. Crucially, phase one of the project revealed the challenge of maintaining a child-centred focus when systems are complicated and siloed, which hindered instead of embraced collaborative practices. Change was most evident in cross-sector opportunities advocating for better health outcomes by placing ‘health’ on the child protection agenda. Participants agreed that, despite challenges and barriers, the integration of the health systems project evolved, and the evolution from phase one is a necessary journey for sustainable change. This is particularly reflected in health governance and leadership and their acknowledgment of the complexity and cultural differences between organisations.
Phase one demonstrated the level of difficulty in creating change, some of which was anticipated and some that was not. Despite these difficulties, phase one strengthened participants desire to improve health outcomes for children in OOHC, which will improve their quality of life during and after care. A shared vision emerged that acknowledges the children and their carers as experts in their own health care planning. Phase one of integrating health systems in Northwest Victoria began with placing health on the agenda for children in OOHC. The next phase will need to implement change to make a positive difference for children, their carers, families and the communities in which they live.
5 CONCLUSION
This study's overall aim was to improve health outcomes for children in OOHC in rural Australia. The objective is better integrated health systems between community health provision and child protection service delivery with support of a health navigator located across multiple sites. The project's first phase revealed the difficulties associated with introducing a new multi-site integrated system, particularly during COVID-19 social restrictions, but also demonstrated the value of shared governance and the ways that partnership building is an imperative foundation for fundamental change and future success. The difficulties in collecting information across different systems reinforced the notion that adequate health care is a significant gap for children in OOHC. The project led to an enhanced understanding of area-based strengths, which in turn supports improved pathways to health care for children in OOHC within rural communities and driving the subsequent phases of the 10-year project.
AUTHOR CONTRIBUTIONS
Corina Modderman: Conceptualization; investigation; funding acquisition; writing – original draft; methodology; validation; visualization; writing – review and editing; data curation; supervision; project administration; formal analysis. Rachael Sanders: Writing – review and editing; writing – original draft; visualization. Emma Cordon: Writing – review and editing; formal analysis. Craig Hocking: Writing – review and editing. Melissa Wade: Writing – review and editing. Werner Vogels: Conceptualization; data curation; funding acquisition; writing – original draft; writing – review and editing; methodology; formal analysis; validation.
ACKNOWLEDGMENTS
We are grateful for the contribution of project members who participated in the study and in facilitating access to documentary evidence. We thank Dr Susan Webster for her expertise and guidance. Open access publishing facilitated by La Trobe University, as part of the Wiley - La Trobe University agreement via the Council of Australian University Librarians.
FUNDING INFORMATION
Department of Families, Fairness and Housing, Grant/Award Number 190967.
ETHICAL APPROVAL
Ethical approval was granted by the La Trobe University Human Ethics Committee in April 2020 (HEC20082).
