General Practice in Tasmania

I work in allied health

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 and 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 not duplicate what is already being done.

Why is care coordination useful?

  • It complements your existing work, doing what you don’t have time and capacity for.
  • It involves thinking in a non-clinical context, not duplicating what you do but working in collaboration, helping to get the client to your appointments, understanding the barriers to treatments and working in a person-centred manner. Clinical work is left to clinicians and clients are referred accordingly.
  • It increases capacity to comprehensively support your clients with their complex medical and social needs.
  • It provides comprehensive home assessments.
  • It delivers person-centred care—working with the client to find out what they want and their willingness to participate and change.
  • It provides ongoing feedback to you and the general practice about assessment findings and interventions.
  • It assists the client to gain access and increase the efficient use of general practice MBS item number health assessments and chronic disease support management programs:
    • Aboriginal and Torres Strait Islander Health Checks (715)
    • Chronic Disease Management Plans (GPMP) (721)
    • Team Care Arrangements (723).

Care coordination adds value

As you are well aware from working in the allied and 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.