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Southern Kids TLC (Transfer to Local Care)

“Being the parent of a medically complex child is a roller coaster and a half most days, we shouldn’t have more struggles just because we live in rural areas”

Children with chronic and complex conditions are likely to experience disjointed care within and across the multiple different health care services they encounter. Unclear communication channels impede family and carers’ access to the right care, in the right place, every time. Difficulties in navigating and sharing crucial clinical information across these services can threaten the quality, safety and continuity of care for this vulnerable group who are at risk of unnecessary presentations to the Emergency Department (ED), avoidable admissions, and parental and provider dissatisfaction.

In 2015, the Sydney Children’s Hospitals Network (SCHN) implemented an integrated model of care for children in metropolitan Sydney, known as KidsGPS, that helped to: reduce presentations to Emergency Department (ED) by 40%; reduce day-only admissions to tertiary hospital by 42%; and improve the quality of care for paediatric patients.

Southern NSW Local Health District (SNSWLHD) Sydney, emerged as a key rural area for scale and spread of the integrated model of care. In 2018, 700 children from SNSW attended over 2000 appointments at SCHN, with 200 of these children attending more than 4 appointments on average throughout the year.  For these children, better coordinated care means less time away from school, greater confidence in their local health teams, their parents having fewer days away from work, less travel and greater feelings of support throughout their care journey. 

The Southern Kids TLC (Transfer to Local Care) Project is an adaption of the successful KidsGPS model for Southern New South Wales Local Health District (SNSWLHD). The transfer to local care initiative identifies opportunities to support children with complex medical conditions and their families closer to home, where safe and appropriate to do so. The initiative focuses on a shared care approach to improving coordination and enhancement of existing services across Southern NSW LHD, providing a more equitable and consistent service to consumers and reducing barriers based on geographical distance. This is achieved through greater recognition of the primary care team locally, development of clear processes aiding in identification of chronic and medically complex children, care coordination and increased utilisation of telehealth and outreach modalities.

It is hoped that this work can support consistency and quality in the way we care for children with chronic and complex medical conditions to better manage care in their local region.

To find out more about how we are striving towards more seamless and integrated care, please contact 

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