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Care Coordination

What is it

Care coordination is a comprehensive approach to deliver more effective health management for people with chronic diseases.

How it works

In the context of care for older people, care coordination encompasses multiple aspects of care delivery including multidisciplinary team meetings, the management of chronic disease, psychosocial assessment and the provision of required care, referral practices, data collection, development of common protocols, information provision and individual clinical treatment. The NSW Chronic Disease Management program works on proactive identification, assessment, enrolment and monitoring of people with complex needs. Five priority disease groups are used to identify people 16 upwards. The key is to proactively identify people at very high risk or high risk of unplanned hospital or Emergency Department presentation.

Resourcing

These models recognise General Practitioners as main medical care providers who provide strong support for patient self-management. Information and communication technology systems provide an enabling infrastructure supported by shared assessment tools and protocols.

Success factors

  • Strong links between Primary Care Practice and Hospital facilities 
  • Shared information and communication technology systems
  • Performance measures and clear accountabilities 
  • Ring fenced funding and dedicated care coordinators co-located with acute and primary care facilities.

Models in operation

Chronic Disease Management Program (most sites). Local relationships between aged care services and Chronic Disease Management program are embryonic.