ADHD Co-Management Nurse Coordinator for Children
Supporting a shared care model between GPs and paediatricians to improve access to ADHD care, strengthen primary care capability and provide care closer to home for children and families.
Community need
Children across the North Coast experience significant delays accessing paediatric assessment and ongoing ADHD care. The region has fewer specialists per capita than NSW and Australia, despite higher use of specialist services. Long wait times can delay diagnosis, treatment and support, increasing the risk of poorer educational, social and health outcomes. Families in rural and regional areas often need to travel long distances for routine medication management and follow-up care. The program addresses these challenges by supporting a shared care model that allows children with stable ADHD to receive ongoing care through their GP while maintaining access to specialist support when required
Our approach
The program uses a shared care model between general practitioners and paediatricians. Children receive assessment, diagnosis and treatment initiation through paediatric services and transition to GP-led management when clinically appropriate. The ADHD Co-Management Nurse Coordinator acts as the link between primary care and specialist services, supporting communication, care navigation, clinical pathways, education and timely access to specialist review. The model aims to provide integrated, value-based care that improves access, continuity and patient experience while making better use of limited specialist resources.
Consultation
The model was developed through an extensive co-design process led by a multidisciplinary ADHD Co-Management Working Group. Participants included general practitioners, Aboriginal Medical Services, public and private paediatricians, paediatric nursing services, HealthPathways clinicians, Healthy North Coast representatives and Northern NSW and Mid North Coast Local Health District leaders. The group reviewed evidence, consulted with other NSW jurisdictions, mapped patient journeys and developed shared clinical workflows, education resources and referral pathways.
Key activities
Coordinate implementation of the ADHD shared care model across the North Coast.
Support integration between general practice and paediatric outpatient services.
Assist families transitioning to ADHD co-management.
Coordinate education, resources and onboarding for GPs.
Support adoption of ADHD HealthPathways and referral processes.
Coordinate escalation and access to paediatric review when required.
Facilitate communication between families, GPs, paediatricians and allied health providers.
Support monitoring, evaluation and quality improvement activities.
Assist transition planning for young people moving from paediatric to adult care services.
Objectives
mprove timely access to high-quality ADHD diagnosis, assessment and support for children.
Increase GP capability and confidence in managing ADHD medication and ongoing care.
Improve collaboration between primary care and specialist paediatric services.
Reduce demand pressures on paediatric outpatient services by enabling appropriate care in primary care settings.
Provide care closer to home for children, families and carers.
Improve care coordination, continuity of care and patient experience.
Support integrated, value-based care for children with ADHD.