Care coordination involves working with a patient to develop a comprehensive plan that helps them take more control of their health and achieve their goals.

Care coordination is for patients with a chronic condition(s), at risk of admission to hospital, or who may have complex needs. It involves the timely coordination of health, community and social services to meet a patient’s needs. For care coordination to succeed, it is crucial that a partnership is developed between the patient, carers and providers.

Care coordination in general practice: who’s involved

To implement care coordination successfully, a whole-of-team and integrated approach to care is essential. Clinical and non-clinical responsibilities are shared across the practice. For example, administrators might manage the logistical aspects of patient groups (e.g. exercise group), nurses might complete diabetes risk screens, GPs review care plans etc. The key contact for the patient is the care coordinator, who leads their planned care, and the team.

The care coordinator is responsible for working with a patient to identify their goals and to coordinate services and providers in order to meet those goals. The care coordinator also supports a patient’s self-management. Read more about care coordination tools, templates and links.

Care coordinators have a clinical background, with expertise in chronic disease self-management, health behaviour change, patient advocacy, navigating complex systems and communicating with people across a broad range of sectors.

Given that care coordination requires a whole-of-team, integrated approach to care, it is important to have agreed processes to communicate important information.