Care coordination tools, templates and links

Goal setting

Goals are an essential part of care coordination because they direct the patient’s and the team’s actions. Goals should be identified by a discussion between the patient and the care coordinator.

Behaviour change

Care planning can encourage patients to adjust their lifestyle or habits. Considering the steps to behavioural change can help health professionals understand what the patient is going through. Is the patient ready, willing and able to change?

• Ready: the ability to prioritise. A patient who identifies a goal with a high level of importance whilst being confident may still refuse change – “I want to do it, but not now”.
• Willing: the extent to which the person wants, desires, or will change – perceived importance. You can ask the patient how important their goal is on a scale of 1-10.
• Able: if a change has a high level of importance and the patient is confident that they can take the actions to achieve their goal, they will start to move in the direction of the change. 

Motivational Interviewing

Motivational interviewing has emerged as a more effective intervention than direct persuasion for promoting change in behaviour. Read more about motivational interviewing here.

Integrated care

Integrated care is an approach that can strengthen care coordination. To integrate a patient’s care effectively, information sharing processes must be formalised between members of the team. Information sharing related to patient care can occur through a huddle, phone calls, a formal protected time such as case conferences, an internal message system, or a written record in the patient file. Information sharing related to a practice’s care coordination processes can occur through regular practice meetings, where all staff attend. Practices may wish to document their chosen methods for information sharing within a care coordination policy.

Additional resources

Behaviour change

• HealthChange Associates Homepage (HealthChange Associates)
• Behaviour change resource library (HealthChange Associates)

Care coordination

• Care Coordinator Position Description Example (SEMPHN)
• Care Coordination Overview (Agency for Healthcare Research and Quality)
• ‘Green Book’- Guidelines for the implementation of prevention in the general practice setting: 3rd edition (RACGP)
• ‘Red Book’- Guidelines for preventive activities in general practice: 9th edition (RACGP)
• Care Coordination (Primary Health Tasmania)

Care planning documents

• GPMP and After Hours Arrangements Example (SEMPHN)
• TCA and After Hours Arrangements Example (SEMPHN)
• GPMP TCA After Hours Action Plan Example (SEMPHN)
• Goal Planning, Supporting Organisations and Action Plan (SEMPHN)
• Osteoporosis GPMP TCA Example (SEMPHN)
• Diabetes Mellitus Type 2 GPMP TCA Example (SEMPHN)
• Quality Care Plan Checklist (Central Queensland, Wide Bay, Sunshine Coast PHN)
• Care Plan Examples (EMR Alliance)

Chronic Disease Management

• CDM resources (SEMPHN)
• Practice Coaching: Chronic disease e-learning module (SEMPHN)
• Empathy in general practice (SEMPHN)
• Forms and Templates including Care Plans, Health Assessments and Referral Forms (SWSPHN)
• Care for people with chronic conditions: Guide for the Community Health Program (Health.vic)
• Online Learning Products (APNA)

Digital Health

• Nellie (SEMPHN)
• POLAR (SEMPHN)
• My Health Record (SEMPHN)

Goal setting

• Types of goals (Health Direct)
• Goal setting and action planning (NHS)
• Goal hierarchies (HealthChange Associates)

Health Coaching

• The Health Coaching Australia (HCA) Model of Health Coaching for Chronic Condition Self-management (CCSM) (Health Coaching Australia)
• Behaviour change and health coaching (Better Conversation)
• Advancing the practice of health coaching: differentiation from wellness coaching (Workplace Health and Safety)
• Health coaching for behaviour change (NHS England)

Health Literacy

• Health Literacy (SEMPHN)
• Tools and resources for health service organisations (Australian Commission on Safety and Quality in Health Care)
• Using the teach back technique (Centre for Culture, Ethnicity and Health)
• Materials and resources for use (The Health Literacy Place)

Integrated Care

• Integrated care - what is it? Does it work? (The Kings Fund)
• Integrated Care Models: An Overview (World Health Organisation)
• Introduction to the Victorian Integrated Care Model – online training (Department of Health and Human Services)
• Primary Care Team Guide (Improving Primary Care)
• Integrated Care Journal (International Journal of Integrated Care)
• Webinar resources (International Foundation for Integrated Care)

MBS

• MBS Online (Department of Health)

Motivational Interviewing

• Guiding patients through complexity: Motivational interviewing for patients with multimorbidity (AJGP)
• Introduction to Motivational Interviewing - video (Bill Matulick)
• Motivational Interviewing in brief consultations: a role play - video (Steve Rollnick)
• Motivational Interviewing Pocket Guide for clinicians (Kylie McKenzie, BA (Hons), MPsych (Clinical), MAPS, Clinical Psychologist)
• Guidelines to Motivational Interviewing (RACGP)
• Motivational Interviewing Homepage (Motivation Interviewing Network of Trainers)

Pathways

• Alcohol and Other Drugs Pathways (SEMPHN)
• Optimal Care Pathways (OCP) for cancer (SEMPHN)
• Statewide Referral Criteria for specialist clinics - referral and clinical pathways (SEMPHN)
• Other localised pathways (SEMPHN)

Patient-centred approach to health care

• Personalised Care (NHS England)
• Person-Centred Care Toolkit (RCGP UK)
• What Matters (Institute of Healthcare Improvement)

Patient-centred medical home

• Health Care Homes Overview (SEMPHN)
• Patient Centred Medical Home Resources (NCPHN)
• Standards for Patient-centred Medical Homes (RACGP)

Refugee and Asylum Seeker Health

• Refugee and Asylum Seeker Health Overview (SEMPHN)

Social Prescribing

• Consumers Health Forum - Social Prescribing
• Social prescribing: linking patients with non-medical support (Medical Journal of Australia)

Local Social Prescribing Programs/Resources:

• • Frankston and Mornington Peninsula Social Prescribing Program
  • Find a WASEMA Friendship Cafe (women only)
  • Find a Men's Shed
  • Find a Neighbourhood House 
  • ADMA Social Prescribing Initiatives listing

Self-management support

• My Health Visit Today Notepad (SEMPHN)
• A Practical Guide to Self-Management Support (The Health Foundation)

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Associated tags

• toolkit