Care coordination

• developing and implementing an integrated care plan with the consumer
• helping the consumer understand and self-manage their conditions
• working with organisations to support the consumer in the community⁵
• improving the appropriateness, coordination and consistency of services
• enhancing choice and flexibility in service delivery
• improving service efficiency and patient outcomes.⁶

Care coordination is particularly useful for people with long-term, complex care needs, particularly those with more than one chronic condition. It can also be useful for:

• people living with mental illness
• people with substance abuse problems
• people with physical conditions including cardiovascular disease, diabetes, respiratory conditions, musculoskeletal conditions and blood-borne viruses
• people in aged care.³

The NSW Ministry of Health defines care coordination as: deliberate, person-centred organisation of patient care activities between providers to facilitate self-management, appropriate care, health outcomes and greater efficiency.³

Care coordination is a comprehensive process that operates at a clinical, organisational, administrative and policy level.

It involves:

• helping people better understand healthcare services available
• assessing and tailoring support to the consumer’s needs and preferences
• identifying which provider the consumer will benefit from seeing next
• streamlining access to, coordination of and transition between services
• understanding what information should be transferred between providers
• improving the quality of information provided to the consumer
• managing accountability and responsibility among health professionals²
• improving consumer satisfaction with the support and services provided
• maximising cost effectiveness from reduced service duplication, reduced costs and better use of specialist services
• helping people achieve their desired health outcomes.

Evidence shows that using a combination of care coordination strategies is generally more successful than only using one approach.⁷ However, further research into the effectiveness of different care coordination strategies is needed to provide greater clarity on the measurable benefits.

In Australia, care coordination is available for specific groups of people who have complex care needs and multiple service providers.¹ Consumers can be referred to the Integrated Team Care Activity Guidelines by the general practitioner who provides the majority of care.⁸

A dedicated care coordinator or case manager is crucial for improving care coordination^{4 9}. However, it is important to note that care coordination is just one component of improving health outcomes for those at risk.

To deliver care coordination, you will need strong people skills, a detailed knowledge of local systems and an understanding of the local community.³

Few care coordinators have specialist training beyond their professional qualifications. Training is usually informal and provided at work by professionals with experience and related training. They will help you develop:

• a high level of trust with the consumer and their family or carer
• collaborative relationships and regular communication with the consumer’s healthcare team
• a suite of targeted interventions to meet the individual needs of consumers.¹⁰