Table 1.

Eligibility criteria for Care Coordination enrollment and three-tiered classification of complexity of coordination

Eligibility:

Children aged 0–19 years who were patients of the SCHN and:

1. Had complex needs, involving multiple health care providers and health services

2. There was no designated key person already coordinating care within a multidisciplinary team

3. There was potential to facilitate a more coordinated approach to the patient’s healthcare needs, in particular for patients who frequently used hospitals services including:

a) More than 4 ED presentations within 12 months;

b) More than 14 days length of stay for any hospitals admission;

c) More than 10 outpatient appointments within the last 12 months;

d) Infants who were medically fragile and identified as being at risk of significant future hospital utilization.

Care coordination complexity levels:

• Tier-1: Integration with primary care only

• Tier-2: Requires integration and shared care plan +/− primary care

• Tier-3: Chronic/complex care coordination among tertiary, local health district and primary care