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

Care coordination

Care planning documents

Chronic Disease Management

Digital Health

Goal setting

Health Coaching

Health Literacy

Integrated Care


Motivational Interviewing


Patient-centred approach to health care

Patient-centred medical home

Refugee and Asylum Seeker Health

Social Prescribing

Local Social Prescribing Programs/Resources:

Self-management support

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