Children's Therapies
The Pod

Care Coordination Service

This is a service for babies and children who present with an identified developing condition or disability which is impacting on or has the potential to significantly impact upon their long term development and / or function.

A care coordinator or specialist nurse advisor may be allocated to the child and their family in order to provide support and advice, this may include;

Coordination of care with other professionals and organisations
Information on local groups and other agencies.
Education including nursery planning
Team Around the Child meetings
Referrals onto other agencies /services (where required).

Care Coordinators work with nurseries/schools, GPs, health visitors, doctors, preschools, and other health professionals. They will link in with other agencies involved in the child’s development to ensure the best wraparound care is given at all times.

The service may organise (with parents/carers agreement), a Team Around the Child meeting to gather relevant professionals with parents/carers to share information and put together a family plan to identify the input and support the child would benefit from in order for them to reach their own potential.

Service criteria

Children referred to the care coordination service will have a significant severe delay in 2 or more areas of their development and will require ongoing support from at least 2 therapists within the Children’s Therapies Team.

Pre-school Children with complex disability and their parents/carers will have an agreed support plan in place for next steps within 2 weeks following initial visit / appointment.

Children can be referred to the service through parental referral, a GP, health visitor, nursery key worker or other health professionals.

Referral

Children for this service will be discussed within the Children’s Therapies triage process

All referrals will triaged in the normal Children’s Therapies process, if a child appears appropriate for care co-ordination at triage, but they have not been referred for this, then the triaging clinicians can suggest that family be asked about care co-ordination.

All children should be triaged for how urgently they should be seen. This will usually fit in with the timescales as defined by the allocated pathway. If the infant or child is in hospital, the care co-ordination team may support with co-ordination for discharge.

All children must be contacted within the 18 week referral to treatment target.

The children can receive time-limited packaged of care throughout their time with Children’s Therapies until the age of 12. This may involve being discharged and re-referred to access further support.

For our North and West Kent areas - Please complete the Children’s Therapies referral form on the Pod – especially if you think therapies will to be involved as well.

Complete Children's Therapies referral form

If you are in East Kent please complete the Children's Therapies Care Coordination Service referral form.

Complete CCCT referral form (east Kent only)

Exclusion criteria

Children will not be accepted into the care coordination service if they are referred after their 4^th birthday unless:

the family have moved into the area and had previously accessed an equivalent service
the child has an acquired brain injury that results in significant developmental delay
the child presents with a degenerative condition diagnosed after their 4^th birthday
they have previously been known to the Care Coordination Team and are under 12 years old.

N.B Referrals will not be accepted for babies and children who have complex medical needs and who do not meet the above criteria. These children should be referred to the Children’s Community Nursing teams.