The Neurodevelopmental Disorder (NDD) care coordination program is a stream under Complex Care, that is a specialized program aimed to improve and support the care of children with neuro-developmental complexity. These children are primarily cared for by community pediatrics, with support from subspecialists at the Alberta Children's Hospital.
The NDD stream provides comprehensive support for patients and families who receive care in the hospital, community, school, or at home. The NDD team is composed of care coordinators, who help patients and families with accessing and navigating the systems and services they need. Care coordination includes patient and family-centered, psycho-social assessment driven, team-based activity designed to meet the needs of children and youth. The NDD partners, alongside the referring care team, work collaboratively to coordinate care and address interrelated medical, social, developmental, educational, and financial needs to achieve optimal health and wellness outcomes for patients and families.
Services Include:
- conduct needs assessment and set priorities
- care coordination across community and AHS
- care planning support
- assist with self-management and self-advocacy / empowerment through education
- link to basic and specialty resources
- enhance accessibility and address disparities / inequities
- support for transition between care settings
- collaborate with family, care providers, school, community, and others
- navigate with stakeholders, identify needs, and next steps with families
- explore community activities and resources
- improve family access and supports
- medical, development, and mental monitoring and information sharing
The team does not assume a primary care / therapy team role. NDD requires active participation from the patient’s care team(s) (e.g., social work, physician, family, school team) and is not considered a discharge plan.