Care coordination

What is care coordination?

Care coordination is a term used to describe working with a patient to develop a comprehensive plan that helps patients 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 (which include the social determinants of health). It is a patient-centred approach that involves the timely coordination of health, community and social services to meet a patient’s needs. It is a partnership between the patient, carers and providers.

Benefits of care coordination for patients

• Better support for self-management
• Access to a coordinated team who know what support and intervention patients need
• Improved understanding of their health
• A proactive approach to a patient’s health
• Increased interaction with a patient’s care team
• Receive emotional, psychological and practical support.

Benefits of care coordination for practices

• Opportunity to improve team interactions
• Building partnerships with providers of healthcare, social and community programs and patients
• Opportunity to be more innovative with care such as telehealth, health coaching, shared medical appointments
• Embedded team-based approaches that enhance patient care
• Clinicians working to the full scope of practice
• More flexibility, innovation and less duplication
• Through an integrated approach to care, staff remain up to date on patients’ progress or issues.

Who, in your practice, is involved in care coordination?

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 could manage the logistical aspects of patient groups (e.g. exercise group), nurses could 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 here.

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

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

Resources

Care coordinator position description (example)

Care planning

Care coordination tools, templates and links