Key messages

  • Care coordination assists in achieving consistency of care between acute and community-based services.
  • Care coordinators are a point of contact for people as they undertake and complete their care plan.
  • In the Health Independence Program (HIP), care coordination is based on the Wagner Chronic Care Model, an evidence-based systems framework.

A general definition for care coordination is ‘the deliberate organisation of patient care activities between two or more participants involved in a patient’s care to facilitate the appropriate delivery of healthcare services’ (see Closing the quality gap: a critical analysis of quality improvement strategies).

The Health Independence Program (HIP) guidelines use the term ‘care coordination’ as the generic term for the multitude of coordination roles in existence to help people accessing the program.

The target population

HIP works with people who:

  • have chronic health conditions and/or complex healthcare needs
  • are experiencing multiple factors - social, environmental, financial and cultural - impacting on their health
  • frequently use hospitals or are at risk of hospitalisation
  • would benefit from care coordination and self-management support. 

Services provided by care coordination

Care coordination helps to achieve consistency of care. It does this through clear communication, linkages and collaborative integrated care planning between acute and community-based services.

The Wagner Chronic Care Model

Care coordination in HIP is based on the Wagner Chronic Care Model, an evidence-based systems framework that assists in the management of care through a more collaborative approach.

The framework recognises the importance of a system-wide approach to ongoing care for people with chronic conditions and complex care needs. Although designed around chronic conditions, the same elements are essential to address the needs of people with complex aged or psychosocial factors impacting on health.

The Wagner Chronic Care model is an evidence-based systems framework that assists in the management of chronic conditions through a more collaborative approach. It recommends linkages across the acute setting, community services, self-management support, specialist care, flexible delivery models of care, shared clinical information systems.

HIP Care Coordination supports an integrated system-wide approach to care for people with chronic and complex care needs. It does this by working across the interface between acute and community-based services. It aims to achieve consistency of care through clear communication, linkages and collaborative integrated care planning.

Care coordinator’s role

Care coordinators support people to navigate the service system and services. They provide the point of contact as people undertake and complete their care plan.

The intensity of the care coordination is based on the level of complexity of a person’s care needs and their self-management capacity. In some instances, HIP clients may need significant input from a care coordinator while others may only need short-term assistance.

The care coordination role can involve:

  • linking the client to required specialist assessment and services
  • being guided by the individual care needs of the client
  • ensuring consistency and continuity in the client’s care
  • liaising and linking with multiple services
  • addressing barriers to engagement, ensuring a sustainable ongoing care plan for the client is established
  • supporting both client self-management and the carer/family.

Complex care coordination provides:

  • care across the continuum
  • tertiary and secondary prevention
  • comprehensive assessment and care planning
  • access to specialist assessment and intervention
  • access to general practitioner management
  • a self-management approach
  • complex psycho-social issues management.