Consumer Enablement Guide

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Care Coordination

Care coordination helps consumers, carers and service providers work together to improve health outcomes for those at greatest risk.1

What is care coordination?

People living with chronic conditions often require complex care from a number of healthcare providers. Care is often fragmented, making it difficult for people to achieve their health, wellness and end-of-life goals.2

Care coordination helps people integrate care across all providers, with the goal of improving health outcomes while containing healthcare costs.3 4

It addresses the psychological, social and behavioural factors that can increase the progression of chronic illnesses, prevent effective self-management strategies and reduce access to treatment. This includes:

  • 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

How to practice care coordination

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

What skills do you need?

A dedicated care coordinator or case manager is crucial for improving care coordination4 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

References

  1. Schizophrenia Fellowship of NSW Inc. Care Coordination. [Position Paper]. Gladesville, NSW: SFNSW; 2012 [updated 2013 Jun; cited 2018 Jan 16].
  2. Antonelli RC, McAllister JW, Popp J. Making Care Coordination a Critical Component of the Pediatric Health System: A Multidisciplinary Framework. New York: The Commonwealth Fund; 2009 [updated 2009 May 21; cited 2018 Jan 16].
  3. Centre for Primary Health Care and Equity UNSW. Rapid Review: Integrated Care Interventions: Final report. Prepared for the NSW Ministry of Health. 2017.
  4. McDonald K, Sundaram V, Bravata D, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 7: Care Coordination). Technical Reviews, No 97. 2007.
  5. Primary Health Care Advisory Group. Better outcomes for people with chronic and complex health conditions: Report of the Primary Health Care Advisory Group 2015. Canberra: Department of Health; 2015 [updated 2016 Mar 31; cited 2018 Jan 16].
  6. Kodner DL. All together now: a conceptual exploration of integrated care. Healthcare Quarterly (Toronto, Ont). 2009;13 Spec No:6.
  7. Larsen K, Perkins D, Harris MF, et al. Coordinating primary health care: an analysis of the outcomes of a systematic review. MJA. 2008;188(8 Suppl):S65.
  8. Commonwealth Department of Health. Funded actvities: Integrated Team Care (ITC). Canberra: Department of Health; 2016 [updated 2016 Oct; cited 2018 Jan 15].
  9. Brown R. The promise of care coordination: Models that Decrease Hospitalizations and Improve Outcomes for Medicare Beneficiaries with Chronic Illnesses. [Report commissioned by the National Coalition on Care Coordination]. Chicago: N3C; 2009 [updated 2009 Mar; cited 2018 Jan 16].
  10. Anderson S, Egan M. Models of Coordination: Ontario Stroke System. 2010 [cited 2018 Jan 16].

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