Holistic support for children with complex needs

Children and teens with complex needs (with more than one diagnosis or need for different support services) often fall between chairs in the public service system. In the Stavanger Municipality, we have worked together with various stakeholders to create a holistic service model, where the child's needs are in focus, and public service providers collaborate to deliver complete support cross-silos.

Complex needs require complex support

It's quite common that a child in contact with social services or other support services needs help from more than one source. For example, they might have both a cognitive disability and a physical disability and need support from a psychiatrist, school, and a physiotherapist. However, without a holistic view of the child and their needs, it might be an inconsistent and split-up service experience. To work seamlessly, the different stakeholders need to collaborate to provide one service based on the child's needs.

A common meeting ground

To solve the problem, we have, together with the different stakeholders - representatives from Stavanger Municipality, Stavanger University Hospital, social services, teachers, and parents - developed the solution Team på tvers ('Cross-over teams'). The temporary team consists of people with different competencies within municipal healthcare and specialist care who support the child and work together with those close to the child – e.g., family and teachers – during a given period of time. The team has the freedom to step outside the regular limits of what the care providers can do individually. That is, the service and support that Team på tvers can deliver together, is significantly ampler than the sum of what each individual player can deliver.

Based on thorough insight-work from stakeholders and users, we have together elaborated the solution Team på Tvers. We have worked with classic service design methodology, using user journey mapping, workshop facilitation, and design sprints to create a shared understanding of the problem and the solution. In addition, we have also worked actively with service prototyping, testing out the solutions to ensure their feasibility, usability, and effectiveness.

One size doesn’t fit all

An essential feature of the design of Team på tvers is that it is tailored to each case. In other words, the constellation and set-up of the team depend entirely on the individual child’s needs, challenges, and social context. Moreover, the measure is intended only to be applied during a limited time period, ensuring that all services are aligned and adequate. Once the period is over, the original team has received the extra support and competence boost necessary to continue on its own.