Authors: (including presenting author): :
Kuok MCI, Chung WH, To S, Wong KL, Yeung YS, Chow CKJ, Lam AKF, Cheng SY, Yeung YM, Chan WKY, Wong MY
Affiliation: :
Department of Paediatrics, Queen Elizabeth Hospital
Keyword 1: :
Integrated service
Keyword 2: :
Complex chronic condition
Introduction: :
Paediatric patients with complex chronic conditions frequently have multisystem involvement and require care from multiple subspecialties. Repeated outpatient visits with transportation challenges increase travel burden and parental stress. A service model that “brings doctors to patient” may reduce these burdens while improving care coordination and family-centred outcomes.
Objectives: :
To establish a daycare-based service that provides multidisciplinary assessment by paediatric subspecialty teams. To enhance patient and family experiences in medical care for children with medical complexity.
Methodology: :
We established a ONE-STOP (ON-going Evaluation by Subspecialty Teams for Optimal Paediatric Care) service for patients with medical complexity. Eligible patients were carefully selected, primarily those requiring long-term home respiratory and feeding support, and classified as GMFCS level V, corresponding to wheelchair-bound patients with limited anti-gravity postural control. Day admissions were coordinated to allow same-day assessment by subspecialty teams, specialist nurses and allied health professionals as required. Blood sampling and other investigations were aligned within same visit whenever possible. Each patient attended 2 to 4 ONE-STOP sessions annually, depending on clinical needs.
Result & Outcome: :
In 2025, 15 patients (mean age 11.7 years) were enrolled. Genetic/syndromic diagnoses were the commonest conditions (40%), followed by cerebral palsy secondary to extreme prematurity/neonatal insults (33%) and inborn errors of metabolism (20%). Eleven (73%) patients required medications for seizure control and spasticity. Feeding support was required in 12 (80%) patients (11 gastrostomy and 1 nasogastric). Nine patients had a tracheostomy and/or required ventilatory support. A total of 41 day-admissions were conducted, comprising 138 subspecialty assessments, including neurology (28%), gastroenterology (21%), endocrinology/metabolic medicine (17%) and respirology (17%). Additionally, 37 evaluations by allied health or specialist nurses were performed, including dietetics (54%) and occupational therapy (24%). Five echocardiograms and one ambulatory blood pressure monitoring were conducted. Overall, parental feedback was highly positive, particularly regarding reduced hospital visit burden for children with limited mobility. The service was estimated to reduce patient travel by around 130 visits. Blood sampling was aligned with medical reviews to reduce venepuncture frequency. A total of 495 prescriptions were managed, allowing medication prescription during a single encounter rather than across multiple subspecialty clinics. This facilitated family care, improved medication record clarity and reduced administrative errors.
