Integrated care for children in rural Australia: barriers and enablers during early implementation

Introduction
Children and young people (CYP) with medical complexity, have high levels of healthcare needs and utilisation, representing 10% of patients attending children’s hospitals, and accounting for 60% of healthcare expenditure in the state of New South Wales (NSW), Australia. Furthermore, 30% of children in NSW live outside major cities and require enhanced local health solutions to manage healthcare needs, reduce travel and family disruptions and limit out-of-pocket expenses. The Rural Kids Guided Personalised Service (RuralKidsGPS) is a co-designed innovative integrated model of care coordination for CYP living with medical complexity, modelled on the successfully implemented and sustained KidsGPS program in tertiary children’s hospitals in Sydney. RuralKidsGPS is being implemented into four rural local health districts (LHDs) across NSW. This study explores early implementation barriers and enablers to inform contextual adaption and ensure scalability across diverse health settings.

Methods
The implementation evaluation is informed by qualitative methods using semi-structured interviews and focus groups, with children and families, healthcare providers embedded researchers, and health service managers. Adopting an inductive approach underpinned by the Consolidated Framework for Implementation Research (CFIR), we identify implementation strategies, barriers and enablers influencing adoption, delivery, and sustainability of RuralKidsGPS. In this early phase of implementation evaluation (6-12 month after commencement) we have focused on implementation outcomes based on Proctor’s framework, including acceptability, appropriateness, adaptability, fidelity, and feasibility.

Results
The interviews demonstrated the variations in setting and context across the LHDs and the adaption of RuralKidsGPS to meet local needs. Different levels of service demand, the time required for engagement with families from diverse socio-economic and cultural backgrounds and different levels of pre-existing service, and staff changes, contribute to the complexity of service implementation and delivery. All four LHDs share borders with jurisdictions outside of NSW, resulting in some children traveling across state or territory borders to access specialist health services. The complexities of sharing and gaining access to healthcare information across jurisdictions has impacted the timely delivery of care coordination and shared care plan development. RuralKidsGPS builds local healthcare capacity to manage CYP living with medical complexity but requires commitment and effort to build relationships with established local services and understanding of processes, and values, whilst conserving local resources. The perceived value and commitment to RuralKidsGPS by nurse care coordinators who leverage local knowledge and networks to deliver family-centred care, is a key enabler. Importantly, reciprocal support from health managers and health care professionals, and access to resources and networks is providing nurse coordinators the power to adapt and implement RuralKidsGPS. During this period, all LHDs were impacted by natural disasters (floods, bushfires) and COVID-19 creating barriers that required those implementing the RuralKidsGPS to flex and adapt.

Conclusion
Early findings highlight the importance of adaptation to local contexts, the challenges and barriers and the resilience of the care coordinators implementing RuralKidsGPS. Care coordination enables families to navigate fragmented, complex health care systems, more efficiently and effectively. This research will inform the development of an implementation guide to support scaling and sustaining similar models of paediatric integrated care.