AUTHOR=Elgen Irene , Heggestad Torhild , Tronstad Rune , Greve Gottfried 

TITLE=Bridging the Gap for Children With Compound Health Challenges: An Intervention Protocol

JOURNAL=Frontiers in Pediatrics

VOLUME=Volume 9 - 2021

YEAR=2021

URL=https://www.frontiersin.org/journals/pediatrics/articles/10.3389/fped.2021.721926

DOI=10.3389/fped.2021.721926

ISSN=2296-2360

ABSTRACT=Background
During the last decades, there is a major shift in the panorama of diseases in children and adolescents. More children are referred to the specialized health care services due to less specific symptoms and more complex health challenges. To improve the care offered these children, the project “Transitioning young patients’ health care trajectories” aims changing the organization of services and develop a new intervention with a more holistic approach. 
Method
This project includes children between 6 and 13 years with three or more referrals to both the pediatric department and the child and adolescent mental health services within a three years period Children with referrals to either the gastroenterology or the neurology units made up the majority of patients. This paper describes the process of developing an intervention where a complementary professional team meets the patient and his/her family altogether for 2.5 hours. The consultation focus on clarifying the complex symptomatology and on problem solving. The bio-psycho-social model is used emphasizing on the patient’s story told on the whiteboard. In the dynamic processes of development, piloting, evaluating, and adjusting the components, feed-back from the patients, their families, professional team members, and external team coaches is important. 
The population includes patients with multiple referrals to specialized health services for combined mental and somatic issues and criterias seemed adequate. The professional team includes pediatrician, psychologist and physiotherapist. Achieving the transformation from a logistic oriented team where members act separately towards a real complementary team, seems to be a success factor. Using bio-psycho-social model with a narrative approach for diagnostics are welcomed by family and professionals.           

Discussion
Developing a new intervention for young children with complex condition focusing on clarifying the condition and make treatment plans is a demanding process in need of focusing on both complementary teams regarding composition and components of the intervention. When re-designing the specialist health service, it is mandatory to anchor all the changes among employees as well as the hospital leadership. Evaluation of long-term outcome is needed to investigate possible benefits from the new intervention.