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Table 5 Recommendations for inclusion in provincial policy statement

From: Improving transitions in care for children with complex and medically fragile needs: a mixed methods study

Adopt the Definitional Framework for Children with Medical Complexity (Cohen et al., 2011) to identify children with intensive care needs in the province of Nova Scotia that are not easily met under existing policies and services.
Work with existing provincial programs and services (i.e. Continuing Care) to develop policies and tools that are unique to a pediatric population.
Develop a role for a pediatric advanced practice nurse in each health zone in Nova Scotia to act as a liaison/resource between the tertiary care facility and children discharged with medical complexities, their families and their health care providers to coordinate care and lead capacity building and education initiatives with local health care providers, children, and families.
Develop a comprehensive discharge plan for every child with complex care needs. The plan must be co-developed and approved by a discharge planner/advanced practice nurse, parent or caregiver-home, or community discharge coordinator prior to discharge from the pediatric tertiary care facility and will consider the medical, psychosocial and developmental requirements for patients to successfully transition back to their home community.
Develop a Complex Care Information Repository (CCIR) for health care providers, administrators, patients and families to store and organize key resources (contact information for key personnel, clinical practice guidelines, community/hospital resources, etc).
Develop an Educational Outreach Strategy to address the knowledge, skills and competency needs of health care providers across Nova Scotia who care for children with medical complexity.