Elderly lady with Nurse

I work in general practice

Primary Health Tasmania understands that many clients have complex and challenging needs. Coordinating these needs can be time-consuming and frustrating, with many clients referred to and receiving services from multiple providers.

Implementation of care coordination can provide clients, their carers and families with comprehensive support. A care coordinator can identify gaps, organise additional support services, arrange medical appointments and complete home assessments. Care coordination also enhances communication between client, multidisciplinary team and other caregivers.

Care coordination benefits clients with complex needs. It can reduce both their and their carers’ stress, and improve their wellbeing. Many people will tell you that they ‘already do care coordination’. Care coordination would add capacity to the work that is already being achieved, increase its scope and span, but would not duplicate what is already being done.

Why implement care coordination?

As you are aware from working in general practice, there are a number of chronic disease support mechanisms already in place. These include:

  • Chronic Disease Management Plans (721) and Team Care Arrangements (723)
  • Health Assessments
  • 45 – 49 year olds
  • 40 – 45 year old type 2 diabetes risk evaluation
  • 75 years and over
  • Aboriginal and Torres Strait Islander Checks 715
  • MBS Items, DMMR (900), Diabetes Cycle of Care, Asthma Cycle of Care
  • Nurse-Led Clinics

Most practices are vibrant, multidisciplinary health hubs that meet the extensive and complex medical needs of their clients. Staff have direct access to a huge number of at-risk clients, and a vast array of clinicians including GPs, nurses, allied health providers and visiting specialists. So how would care coordinators be useful in addition to what you already do? They could:

  • complement existing work
  • increase capacity to comprehensively support your clients with their complex needs, both medical and social
  • provide home assessments to those unable to have home visits in any other capacity
  • review at risk/complex clients – NDD, cardiac, respiratory, musculoskeletal, diabetic and the frail aged
  • deliver person-centred care.

Care coordination adds value

As you are well aware from working in primary health space, there are a number of clients with chronic diseases and multiple complex comorbidities that continually return to your practice without any improvement or participation in treatment programs. Seeing clients with unresolved social and medical problems becomes frustrating and time-consuming for clinicians and gets in the way of completing specialist assessments and interventions. Chronic disease clients often have complex issues and concerns that impede their ability to improve their health and wellbeing.

Effective communication between care coordinators, clients, health providers and other organisations is essential to providing continuous, ongoing care that brings maximum benefit to the client. It is essential to recognise that a single organisation or person cannot be entirely responsible for providing all the support required by clients and their carers. Care coordinators are responsible for facilitating the involvement of the correct people and support structures for the client at the correct times.