Koorliny Moort

Disclaimer These guidelines have been produced to guide clinical decision making for general practitioners (GPs). They are not strict protocols. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.

 

Koorliny Moort means Walking with Families in the language of the Noongar people of the Whadjuk Nation. The Noongar people are the traditional owners of the land on which Perth Children’s Hospital is located.

Introduction

‘Koorliny Moort’ (KM) is a statewide tertiary paediatric service for Aboriginal children and their families based at Perth Children’s Hospital (PCH) providing culturally appropriate safe and secure healthcare for Aboriginal children and their families.

KM operates two streams of care:

1. Paediatric outpatient services (including outreach)
2. an Ambulatory care coordination program

1. Paediatric Outpatient Services

Koorliny Moort provides holistic general and developmental paediatrician-run outreach clinics for Aboriginal children and adolescents who have evidence of non-engagement in mainstream services.

When to refer to Koorliny Moort:

If a Paediatrician assessment for medical or neurodevelopmental concerns is required for Aboriginal children who are marginalised, at risk and unable to access mainstream paediatric services in the Perth Metropolitan region.

• All referrals to Koorliny Moort must have a completed Koorliny Moort referral form.

Priority Criteria:

Children Under 5 years of age:

• In the care of the CEO of the Department of Communities – Child Protection and Family Support, OR
• No longer in the care of either biological parent.

Children Over 5 years of age:

• More than 2 out-of-home care placements or in residential care
• Non-engagement or risk of non-engagement in the school environment (e.g. multiple suspensions or identification by school staff as being at risk of exclusion)
• Involvement with Juvenile Justice, either preceding or following detainment at Banksia Hill Detention Centre

Koorliny Moort Paediatric Outpatient Services (clinics) are delivered:

• Fortnightly at PCH
• Weekly across a number of sites in the Perth metropolitan area

2. Care Coordination Program

A state-wide nurse-led care coordination program that supports Aboriginal children and their families via navigation, integration, coordination and advocacy across WA health (tertiary and primary) and community services.

The care coordination program is an outpatient time-limited service.

Eligibility:

Children must:

• Identify as Aboriginal and are aged 16 years or younger
• Live anywhere in Western Australia
• Have planned hospital appointments at PCH with two or more specialties
• Have complex health care needs
• Have family/carer consent to engage

Koorliny Moort provides care coordination by:

• Coordinating and combining PCH hospital appointments to minimise the need for frequent travel
• Collaborating with local Aboriginal Medical Services’ (AMS) and Patient Assisted Transport Scheme (PATS) Offices
• Navigating options for care closer to home
• Supporting shared information across health services including GPs
• Providing health advice, social, cultural and family support
• Facilitating telehealth appointments with PCH specialities
• Collaborating with Aboriginal Community Controlled Health Services (ACCHS) and other community services to help families meet their health care needs
• Supporting families at PCH appointments by liaising with Aboriginal Health Liaison Officers (AHLO’s) and Aboriginal Health Practitioners (AHP)

Pre-referral management

Family Support

• If there are issues with:
  • Poor school attendance
  • Significant parental mental and/or physical health concerns impacting child
  • Challenges to attend appointments
  • Homelessness
  • Food insecurity
  • Financial hardship
  • Barriers to clinic attendance or completing treatment
• Consider referrals to:
  • Moorditj Koort Aboriginal Corporation
  • Wungening Aboriginal Corporation
  • Department of Communities and/or
  • For children under 5 years old: Child and Adolescent Community Health-Aboriginal Health Team. See attached brochure.

Accommodation

• Ensure child and family are in stable accommodation.
• If unstable, refer to:
  • Department of Communities-Priority Housing Assistance
  • Advocacy centre for support with housing and homelesness:
  • Daydawn Advocacy Centre
  • Crisis support: Indigo Junction
  • Centrecare

Developmental Trauma exposure

• For children with developmental trauma exposure, consider:
  • Referral to trauma informed therapy: e.g. Yorgum Healing Services
  • Parenting programs:
    • Child/Maternal Health • Derbarl Yerrigan • Aboriginal Medical Health Service (dyhs.org.au)
    • Ngala- Ngalang Moort Ngalang Kurlangah (Our Family Our Children)
    • Ngala- Circle of Security parenting
    • CAHS Circle of Security Parenting Program
    • Triple P-Positive Parenting Program
  • A General Practitioner referral for Mental Health Treatment Plan
  • Referral to Child and Adolescent Mental Health Service

School support

• If child is school-aged and has neurodevelopmental concerns, ensure School of Special Educational Needs Medical & Mental Health (SSEN:MMH) consent form is completed and sent with Koorliny Moort referral form.
• Request school psychologist input if child is having behavioural, learning and emotional regulation difficulties at school.
  • Write to the school principal to request input, noting that further assistance may be indicated and can be requested by a school principal to involve School of Special Educational Needs: Behaviour & Engagement (SSEN:BE) if appropriate
• If appropriate, the school psychologist may conduct a cognitive assessment in preparation for the child’s paediatric appointment

Bloods

• Where indicated, ensure nutritional bloods (FBC, iron studies, Vitamin D, Folate, Vitamin B12, Thyroid function) are taken.
• Begin treatment of Iron deficiency and Vitamin D deficiency as needed
  • PCH Iron deficiency and iron deficiency anaemia Pre Referral Guideline.
  • Royal Children’s Hospital – Vitamin D deficiency clinical practice guidelines.
  • Keeping our Mob Healthy iron deficiency.
  • Keeping our Mob Healthy health facts.

Anthropometric measurements

• Height
• Weight
• Calculate BMI percentile and Z-score using PediTools

Obesity management initiated if indicated

• PCH Obesity pre referral guideline
• Better Health Program referral
• PCH Healthy Weight Service
• Diet advice provided (e.g. Raising Children’s network- Healthy food everyday: Aboriginal families)

Immunisations

• Confirm immunisations are up-to-date according to the appropriate immunisation schedule.

How to refer

• Routine non-urgent referrals from a GP, Consultant, Nurse Practitioner or a Private Specialist should go to the Central Referral Service. Guide for referring to WA public outpatient services (health.wa.gov.au)
• Routine non-urgent referrals from private hospitals go to the PCH Referral Office (Fax: 6456 0097 or email PCH.Referrals@health.wa.gov.au).
• Urgent referrals (less than seven days) go to the PCH Referral Office. Please call Perth Children’s Hospital Switch on 6456 222 to discuss referral with a Koorliny Moort clinician.

Essential information to include in your referral

• Koorliny Moort referral form
• School of Special Educational Needs Medical & Mental Health (SSEN:MMH) consent form
• Any relevant results from bloods
• If any treatment has been commenced

Reviewer/Team:	Koorliny Moort	Last reviewed:	July 2025
		Review date:	July 2028

This document can be made available in alternative formats on request for a person with a disability.