Guidelines. We re working with you and your clients to improve their health and wellbeing

Guidelines We re working with you and your clients to improve their health and wellbeing

Published April 2016 TASMANIA An Australian Government Initiative While the Australian Government helped fund this resource, it has not reviewed the content and is not responsible for any injury, loss or damage however arising from the use of or reliance on the information provided herein. Care Coordination Program Guidelines ABN 47 082 572 629 GPO Box 1827 Hobart TAS 7001 Level 4, 15 Victoria Street, Hobart 7000 t 03 6213 8200 f 03 6213 8260 e info@primaryhealthtas.com.au www.primaryhealthtas.com.au 2 Care Coordination Program Guidelines

Contents About Primary Health Tasmania 5 Context 5 Introduction 6 Vision, aims and goals 7 Definitions 8 The principles of care coordination 9 Expected benefits of care coordination 10 Program description 11 Care Coordination Program 12 Model One: Care coordinators directly employed by Primary Health Tasmania 12 Model Two: Commissioned organisations 12 Examples 13 Care coordination service pathway for chronic disease and Aboriginal health 15 Commissioned organisations 16 Flexible funding/supplementary services 17 Management of funds 17 Recommended uses 17 Care coordinators qualifications and skills 18 Resources 20 Services map for chronic disease and Aboriginal health 23 3

4 Care Coordination Program Guidelines

About Primary Health Tasmania Primary Health Tasmania is a nongovernment, not-for-profit organisation working to connect care and keep Tasmanians well and out of hospital. We are one of 31 primary health networks (PHNs) established nationally on 1 July 2015 as part of the Australian Government s Primary Health Networks Program. The Australian Government has set the following objectives for PHNs nationally: Increase the efficiency and effectiveness of medical services for patients, particularly those at risk of poor health outcomes; and Improve coordination of care to ensure patients receive the right care in the right place at the right time. We have strong working relationships with a broad range of private, public and community sector organisations across primary, acute, aged and social care. This puts us in good stead in our push for a coordinated, primary care-focused health system delivering the right care in the right place at the right time by the right people. More information is available on the Primary Health Tasmania website www.primaryhealthtas.com.au Context Australians face significant challenges in the delivery of quality health care to people with complex and chronic health conditions. We are increasingly living with chronic conditions such as heart disease, diabetes, cancers, respiratory disease and mental health conditions. The current health system is not set up to effectively manage long term conditions therefore stronger, more effective and better integrated and coordinated primary care services are the best way to achieve better outcomes for Australians. Taking snippets of information from the State of Public Health report 2013 and Health Indicators Tasmania 2013 1, we can see in Tasmania: Improving health among the population Health status parallels with regional Australia, with health differences associated and linked with socioeconomic and cultural conditions Increased obesity Increased behavioural risk factors (smoking, drinking and inactivity) Increased hospitalisation rates of >65yrs with chronic conditions All hospitalisation rates increasing Increasing numbers with cancer as numbers of aged Tasmanians increase What does this mean? We are living longer however, ageing population and longevity are leading to larger numbers of older people with disability and severe or profound activity limitation. A recommendation from the Primary Health Care Advisory Group is better coordination of the care of people with chronic disease. There is strong evidence that better coordination of the care of people with chronic disease achieves improvements in their quality of life and health outcomes and as a result reduces unnecessary and inappropriate use of health services including potentially avoidable hospital presentations and admissions. Care coordination is fundamental to improving the quality of care for individual clients and populations. The benefits of care coordination extend not only to clients, but all the components of a healthcare system and for a wide variety of settings and diverse client populations. The fragmentation of services for chronically ill clients has led to inadequate coordination of care across settings and providers. Gaps in communication across healthcare providers sites leads to fragmentation, poorer outcomes and lower satisfaction for both the client and the provider. When information flows efficiently, all aspects of care can improve significantly. 1 State of Public Health report 2013 and Health Indicators 2013, Population Health, DHHS, Tasmania 5

Introduction Primary Health Tasmania s statewide Care Coordination Program has delivered services to at least 5500 people since its small beginnings. It recently combined with the Aboriginal Health Program (formerly Closing the Gap Care Coordination Program and Supplementary Services Program). The Care Coordination Program is reaching far into the Tasmanian community, providing service delivery where clients most need it in their local area. Care coordination involves deliberately organising client-centred activities and sharing information among the health service providers involved. This planned and managed approach ensures that the best health outcomes are achieved for clients and that health services are effectively and efficiently used. The growing complexity of providing care, increasing numbers of clients with chronic disease, and exploding healthcare costs highlight the need for improved care integration through the efficient and effective use of resources without increasing expenditure. The program was implemented with a hybrid commissioning model where each funded organisation was provided with our Care Coordination Guidelines, a suite of tools and resources to use with contractual outcomes KPIs, an online reporting system, comprehensive ongoing support to implement the program from Primary Health Tasmania staff through one-on-one visits, networks and the provision of education and training. We directly employed care coordinators in identified gaps, especially in relation to acute care and hospital prevention. During the implementation of the program, it became apparent that coordination of care involved much more than chronic disease management and, although a lot of people, organisations and sectors, were directly involved in the coordination of care, there were some obvious overlaps and gaps across settings and providers. Implementing person-centred care and using a suite of tools, care coordinators could provide a broader model of care, increase communication and ensure continuity of care. When information flows efficiently, all aspects of care can improve significantly. It was imperative to recognise that general practice remains key to the feedback and communication loops of client s assessments and outcomes. 6 Care Coordination Program Guidelines

Vision, aims and goals Vision The care of Tasmanians with chronic disease is better planned and managed and inappropriate use of health services is reduced All Tasmanians have access to planned and managed service coordination that best meets their needs Aims To provide comprehensive, evidence-based care coordination for people with chronic and/or complex conditions To engage and support clients to take a proactive role in the ongoing management of their chronic condition Goals To ensure clients have capacity to be in control of their health care To improve access to necessary services to help support improved health outcomes for Tasmanians particularly for people with chronic and/or complex conditions To bring about more effective and efficient use of limited health and community resources To reduce inappropriate and avoidable service use across the healthcare sector 7

Definitions Care coordination is defined as: the deliberate organisation of personcentred care between and with those involved in the care to facilitate the planning and management of chronic disease and appropriate use of health services. Organising care often managed by the exchange of information among participants responsible for different aspects of care, education and support. A chronic medical condition is defined as: one that has been (or is likely to be) present for six months or longer. 1 1 www.health.gov.au/internet/main/publishing.nsf/content/ mbsprimarycare-chronicdisease-pdf-infosheet 8 Care Coordination Program Guidelines

The principles of care coordination There are a number of principles that underpin an effective care coordination program 7 Wellness Clients accessing care coordination must have their right to privacy and confidentiality upheld at all times. Appropriate consents must be obtained whenever information is shared with third parties in accordance with relevant legislation and principles (The Privacy Act 1988 (Cth) and the National Privacy Principles) https://www.oaic.gov.au/privacy-law/privacy-act/ and https://www.oaic.gov.au/privacy-law/privacyarchive/privacy-resources-archive/national-privacyprinciples Personcentred care 2 Communication 6 Confidentiality Care Coordination 3 Accessible and equitable 5 Quality and safety 4 Accountability 1. Person-centred Care Person-centred care forms the basis of care coordination. The person is placed at the centre of their health and well-being, creating a respectful and collaborative partnership between the care coordinator, the person, carer and their family. 2. Communication Stakeholders in the client s health and wellbeing must be engaged with each other and the care coordinator. A care coordinator must involve, engage, communicate and collaborate with all stakeholders who are, or who need to be, involved in the client s care. 3. Accessible and Equitable The program is accessible to clients in the community. It is also affordable and culturally sensitive, recognising the diversity that exists amongst cultural, urban, regional and remote communities and individuals. 4. Accountability An effective care coordinator is open to regular and transparent performance monitoring, including clinical governance, assessment of risk, review and evaluation. A care coordinator works within their organisational boundaries, policies, procedures and scope of practice. 5. Quality and Safety All services provided by a care coordinator must be of a high quality in accordance with the Australian Commission on Safety of Quality in Health Care http://www.safetyandquality.gov.au/. Services are to be person-centred, safe and relevant to the needs of the clients seeking services. 6. Confidentiality 7. Wellness A care coordinator encourages a wellness approach that focuses on and improves a person s capability, motivation and commitment to maintain independence with the main aim to achieve a client s personal goals. 9

Expected benefits of care coordination Effective management of chronic health conditions improves health outcomes, provides people with a better quality of life and keeps them out of hospital. An effective care coordinator communicates the client s needs and preferences at the right time and to the right people. This collaborative communication reinforces the understanding that the client and their family are the centre of the partnership. Successful care coordination connects people with chronic disease to community-based models of support and care rather than accessing services in an acute setting. Care coordination has proven to be most successful when there is a close relationship between the client, their GP and the care coordinator. It is anticipated that, through the implementation of care coordination, improvements in health outcomes will be achieved by: Assisting people in understanding their chronic condition and supporting clients to better manage on a daily basis through identification of signs that their condition may require further attention Assisting clients to actively participate in their plan of care Connecting individuals to the support and services in the community Providing access to necessary services to help support improved health outcomes for clients Assisting/educating service providers to have a personcentred focus to service delivery and the role of the client in ongoing management of their health condition In accordance with these key identified areas of improvement, other areas of improvement that may enable and/or contribute to systematic and sustainable change include: Improvement in client and carer wellbeing, independence and resilience Increased client and carer understanding of health literacy and strengthening their ability to self manage Improvement in appropriate and timely access to primary healthcare services More effective healthcare consumption, for example: increased use of primary healthcare services and after hours services, and decreased use of acute sector-based emergency services Increased capacity in the existing workforce (skills) networking and communication Key stakeholder engagement and communication resulting in wider community engagement and participation e.g.; through community groups and neighbourhoods Improve clients access and understanding of health and community care services designed to support their desired health outcomes Clients not linked into general practice services and available care options are encouraged and assisted to access these services in line with chronic disease best practice 10 Care Coordination Program Guidelines

Program description The Care Coordination Program is unique in Tasmania and has taken three years to design, implement and evaluate. This process was seen as critical to develop an evidence-based and consistent approach to care coordination. Care coordination is a key tool in the care of clients with complex health needs, providing longer term tangible benefit for clients and providers across the health system. Primary Health Tasmania has implemented care coordination models in Tasmania. Strategies put in place to support the implementation of these models included: Consistent tools and systems for client referral, intake, assessment, consent, clinical documentation and pathways A comprehensive induction, training and support process. This support is ongoing with network forums, education and training opportunities. The regional program coordinators are responsible for contract implementation, management and compliance and have regular contact with all care coordinators A single point of entry and web portal used for data collection, review, evaluation, KPIs and reporting The development of an online learning platform informing participants on the skills required to implement care coordination in their everyday practice and in their organisations www.carecoordination.com.au The program has two components: 1. Care coordination services provided by qualified health workers (e.g. nurses or alternative qualified health workforce) in a primary healthcare setting including: Care coordinators directly employed by Primary Health Tasmania Care coordinators commissioned in general practice and the community sector Clinical care coordinators commissioned in the acute sector (disease specific) 2. Flexible funding/supplementary services accessible on behalf of program participants to address any urgent unmet service or equipment needs of clients 11

Care Coordination Program Primary Health Tasmania has implemented a statewide Care Coordination Program consisting of two models. The program is aimed at all Tasmanians who have multiple complex chronic conditions including but not limited to: Neurodegenerative disorders (NDD), Parkinson s disease, dementia-related conditions, multiple sclerosis, Huntington s disease and motor neurone disease Respiratory disease including chronic obstructive pulmonary disease (COPD) Diabetes Cardiovascular disease Cancer Renal disease Musculoskeletal conditions (limited to lower back pain, osteoporosis and arthritis) The Care Coordination Program recognises that general practice is the primary provider of client care in the community. Therefore, irrespective of point of referral, a discussion with general practice is encouraged. Clients not linked into general practice services and available care options will be encouraged and assisted to do so. Model One: Care coordinators directly employed by Primary Health Tasmania Primary Health Tasmania delivered a statewide Care Coordination Program. We recruited appropriately qualified and experienced care coordinators to work statewide (Launceston Northern Integrated Care Service (NICS), Hobart and Ulverstone). Our employed care coordinators provide a needsbased service in close association with the acute sector across all regions providing in-reach services and direct referral pathways. practice and other service providers to enable continuity of care. Care coordinators also provide an outreach service across a number of sites including rural areas (West Coast, East Coast and outlying regions of Launceston e.g.; Scottsdale). This ensures that rural clients and areas have access to the program and clients do not have to travel to central locations. The care coordinators develop a close relationship with rural service providers. Model Two: Commissioned organisations The second model of care coordination comprises commissioned organisations within (but not limited to) general practice, acute sector (both private and public), primary care and community sectors. These organisations provide care coordination in accordance with the Primary Health Tasmania Care Coordination Guidelines. Commissioned organisations are guided in the implementation of the Care Coordination Program model and provided with all the related tools and systems. This ensures a consistency of approach while allowing the organisation some level of flexibility with regard to service delivery mechanisms. Commissioned organisations will be required to meet contract deliverables (KPIs) that ensure a consistency of approach to data collection and outcome measurements. Commissioned care coordination service providers have been selected through an Expression of Interest (EOI) process evaluated by a selection panel against specified selection criteria. The Care Coordination Program accepts multidisciplinary referrals from a variety of locations and service providers. Care coordinators triage and enrol patients and complete a comprehensive assessment including health care/support needs, sharing all assessments, plans, referrals and interventions to relevant health and community service providers as required. It is essential to maintain continual communication with the clients general 12 Care Coordination Program Guidelines

Example 1: General practice model This model supports the direct employment of care coordinators by general practice. The care coordinators manage a client base drawn from the general practice patient load. Care coordination allows the interrogation of patient data, the identification of clients within the disease scope and key metrics. It allows direct access to clinical software, clinicians notes and interventions (including GPs, nurses, allied health teams and visiting specialists). This model uses the Medicare Benefits Scheme (MBS) in addition to program funding. The MBS, if used to its maximum efficiency, should enhance the current business model. Benefits: 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 visiting in any other capacity Review at risk/complex clients NDD, cardiac, respiratory, musculoskeletal, diabetes as well as the frail aged Delivery of person-centred care Example 2: Rural community model: care coordinators working in an integrative model in rural communities (e.g. Longford, Circular Head, Huon Valley and Derwent Valley) This model supports organisations in the rural community to work collaboratively, collectively and in an integrated way, allowing one of the organisations to be the fund holder while providing access to the service. This model is dependent upon collaboration, multidisciplinary and multi-sectorial referral pathways. This model has proven to take a considerable amount of time to work comprehensively with the key stakeholders (general practices, hospitals, aged and community providers). The fund holder ensures that access to the program is available to all service providers in the region (for example, an aged care facility holds the funding, while care coordinators work across all health sectors to provide the necessary community support). Example 3: Acute sector model: Tasmanian Health Service clinical care coordinator (disease specific COPD) The model reviews management of clients with stable COPD and clients who have frequent presentations to hospital and puts supports in place to enable increased care in the community and less on acute care service provision. The program provides an outreach service to coordinate consistent and continuous care and to support clients to self-manage their disease. Referrals are sent direct to care coordinators by healthcare professionals or government and non-government agencies. Key features: Coordinated and integrated care planning inclusive of: Discharge support for clients who have been admitted with a COPD exacerbation Assessment and monitoring of health issues Inhaler medication monitoring COPD education for clients and staff Chronic disease self-management Access and referral to support services Example 4: Aged care model This model places a care coordinator within a large organisation that delivers Commonwealth Home Support Programmes and other community-based aged care services. Organisations that deliver services to the aged community can have restrictions on the boundaries of their work with clients due to funding, time and resource constraints. A care coordinator can provide a safety net for the clients who fall through these gaps. They provide a wholistic assessment at home that also considers their health, family and social needs. Example 5: Paediatric model This model has provided support to the families of children with chronic and complex health conditions to navigate the health system and access services appropriate to their needs. Care coordination follows referral pathways from the acute sector such as paediatric outpatient clinics, women s and children s services and community-based paediatricians, GPs and disability services. This has led to improved integration and communication between service providers such as school services, children s allied health, child protection and disability services, keeping the child s general practice and paediatrians in the loop. 13

My Mum s care coordinator has been great. She has given Mum access to services we didn t know existed and helped with health (dental and physio) issues she had been struggling with for some time. The care coordinator was caring and efficient and kept my sister and me informed at all times (my Mum is often forgetful). I cannot recommend this service highly enough. Thank you. 14 Care Coordination Program Guidelines

Care coordination service pathway for chronic disease and Aboriginal health MULTI- DISCIPLINARY REFERRAL TRIAGE PRE- ASSESSMENT ASSESSMENT PROCESS ACTIVE (COMPREHENSIVE CLIENT SUPPORT & PLANNING) General Practice Check for suitability against criteria Acknowledgment of referral Gain client consent Develop short term care plan/goals of care Acute Sector Allied Health Services Community Services Aged Care Disability Primary Health Tasmania Programs Self-referrals Call to discuss with referrer if necessary If No If Yes Identify general practice; discuss client management if associated with an organisation commissioned by Primary Health Tasmania Return with feedback to referrer Suggestions and/or referrals to any other suitable service Identify general practice (link clients to GP if unknown) Consult and communicate with key contacts prior to home assessment Also consider: GP, ACAT, My Aged Care, Regional Assessment Services, Tas Carepoint, disability (NDIS), palliative care and organisations commissioned by Primary Health Tasmania Complete a comprehensive assessment preferably in the home Consider social and family network, health condition and any supports Client self-assessment Feedback to general practice Communicate with key contacts and general practice with assessment interventions Referral to other specialist service providers as identified Regular communication with client Review and allocate flexible funding as required Review and implement changes as required MAINTENANCE Ongoing monitoring with client Regular review of short term care plan/goals of care Ongoing communication with care team The level of support is decreased over time as the client is able to self-manage DISCHARGE (LINKED TO APPROPRIATE SERVICES) Client linked to appropriate services Discuss discharge with client Notify general practice of outcomes and discharge Option for re-referral and/or client selfreferral as needed 15

Commissioned organisations Primary Health Tasmania commissioning is defined as: The strategic planning and investment in quality primary healthcare services with the goal of maximising health gains for the population and efficiency for the health system Organisations will be commissioned following a comprehensive needs assessment, gap analysis, and service system design and implementation process with continual stakeholder engagement. A tender process will be followed to recruit service providers as required. Expectations of commissioned organisations Organisations/providers that are commissioned to deliver care coordination services under this program are expected to: Deliver the program according to the care coordination guidelines Ensure the client s GP remains central to the client s care plan and that the GP is kept informed about the care of their client Embed the Primary Health Tasmania guidelines for Shared Transfer of Care Keep up to date with current service providers and networks in the region Provide care coordination services through recruiting qualified health workers Enrol clients to the program in accordance with agreed eligibility criteria and through an informed consent process aligned with a person-centred approach for goal setting and care Meet client targets according to the contract Be currently delivering services to the target group Use the Primary Health Tasmania care coordination web portal to complete reporting requirements Work within the referral pathways specified by Primary Health Tasmania Refer to appropriate programs such as Aboriginal Health and DVA as identified in the Client Assessment Tool Use flexible funding/supplementary services in accordance with the eligibility criteria defined by Primary Health Tasmania Meet all contractual activity and financial reporting requirements specified by Primary Health Tasmania including reporting on the number of participants receiving care under the program and the health conditions affecting them Work in accordance with the recommended service pathway (refer to page 15) 16 Care Coordination Program Guidelines

Flexible funding/ supplementary services Flexible funding/supplementary services is for clients enrolled in the program. Care coordinators can access this funding on behalf of clients. Flexible funding/supplementary services is limited. Priority for use is given to respond to urgent needs. It is not intended to fund all of the follow-up care required by clients and should only be used where other services are not available in a clinically acceptable timeframe. It is intended for: Addressing risk factors, such as a waiting period for a service longer than is clinically appropriate Purchasing clinically appropriate services that are not available through other funded sources for a limited period of time Helping assist clients with access to medical specialist and allied health services, where these services are not otherwise accessible or available in a clinically acceptable timeframe Assisting clients with travel beyond the closest available regional service in cases of extreme urgency In such cases, the care coordinator ensures that all other funding options (e.g. patient assisted travel schemes) have been exhausted and that the most cost effective means of transport (and any essential accommodation) is used. For example, flexible funding/ supplementary services may be used to fund the difference between the full cost of travel and any funds provided through alternative funding mechanisms. Management of funds Commissioned service providers are allocated a predetermined amount of flexible funds, calculated as an average amount per expected number of clients over a period of time, for use in accordance with the defined criteria and reporting requirements. The use of an average amount per client recognises that some clients may need to use more flexible funding than others, and it is up to the commissioned service providers to manage the overall spend within their predetermined amount. Management of the flexible funding/supplementary services will be underpinned by relevant Primary Health Tasmania policies and procedures and will be carefully monitored and reported on. Commissioned organisations must report on financial expenditure on the web portal and templates provided. cases or expenditure outside their allocated amounts, or for approval of expenditure beyond the predetermined maximum limit. Recommended uses Category allowable use (subject to other funding sources being exhausted): 1. Purchase of specialist medical services Payment of fee for service (where MBS rebates are not available) or gap fees for one-off consultation and not ongoing appointments. 2. Purchase of allied health services Payment of fee for service (where MBS rebates are not available) for a limited period of time. Additional allied health services may be purchased. 3. Travel and transport To fully pay for a client s travel to the closest regionally available health care professional (taxi, bus or other alternative). To fund the difference between the full cost of travel and any funds provided through alternative funding mechanisms. To fund accommodation where it is necessary for the client to travel away from their local community. (Travel beyond the closest available regional service may be supported in cases of extreme urgency.) 4. Equipment and medical aids The medical aid is not available through any other program in a clinically acceptable timeframe. The need for the medical aid is related to the client s chronic diseases. The client is educated on the use and maintenance of the medical aid. Purchase and/or hire of essential equipment. The care coordinator is expected to work with the client s GP and other allied health professionals to determine need. 5. Community-based services One-off services such as home maintenance and cleaning to support clients if there are safety issues for the client while awaiting assessment or approval of packages of care from other sources. Commissioned organisations may liaise with the manager of care coordination, to review individual 17

Care coordinators qualifications and skills Motivational interviewing Health literacy Person-centred care Cultural awareness Communication Self-management Care coordinators are required to be suitably competent health professionals with relevant qualifications and experience and/or registered with The Australian Health Professional Registration Authority (AHPRA) and a current working with vulnerable people check. Care coordinators are required to demonstrate knowledge of the following: The difference between care coordination and case management The health services how to access and how services are delivered in the community and sector General practice and their systems The aged care sector, residential facilities and the community and health packages including consumer-directed care packages The Aboriginal Health Program (formerly Closing the Gap Care Coordination Program), Department of Veterans Affairs and Coordinated Veterans Care programs Advance care planning and enduring guardianship requirements Primary Health Tasmania guidelines for improving the quality of shared transfer of care for people living with chronic complex needs Care coordinators should possess the ability to: Use a person-centred approach to planning and coordinating care Work collaboratively with a range of health professionals Demonstrate competency (or the ability to quickly acquire skills) in comprehensive client assessment (including aged, chronic disease, falls risk) Work across program boundaries including the acute sector Advocate on behalf of clients Promote health literacy and client self-management 18 Care Coordination Program Guidelines

Complete Your communication must convey all the information required by the audience. Courteous Be respectful of the person who is receiving your information. Be polite, sincere, judicious, reflective and enthusiastic in your communication. Considerate Effective communication takes into account the audience s background, education level, mindset and anything else that may impact on their ability to understand the conveyed message. Clear Communicate one message or idea at a time. Avoid overloading the audience with too many different ideas or messages and break down the information into manageable chunks. The seven Cs of communication Correct Always ensure your communication is grammatically correct. Concise Effective communication should use the least amount of words necessary to convey the required information, without sacrificing the other elements of communication. Concrete Effective communication is clear and particular. Avoid ambiguity in your message. What skills and attributes will you need as a care coordinator? You will need to focus on person-centred care. Person-centred care is a fundamental part of care coordination. It is about looking at the bigger picture understanding what else is happening in their life and how it is affecting them. When we understand and appreciate the bigger picture, we can place the person at the centre of their health and wellbeing. You will need to understand the impact and power that self-management support can bring to your clients. Self-management support is the assistance that care coordinators give clients with chronic disease in order to encourage daily decisions that improve health-related behaviours and clinical outcomes. The purpose of self-management support is to aid and inspire clients to become informed about their conditions and take an active role in their treatment. You will need to appreciate the importance of a client s health literacy. It plays a vital role in the management of their health. It underpins their self-management, it is intimately connected to person-centred care, and is fundamental to effective care coordination. With increased health literacy, the individual understands the instructions given to them, are able to question, process and evaluate these instructions, understand how and when to implement these instructions and evaluate the health outcome in the context of their overall health management. You will need to be an effective motivational interviewer. Motivational interviewing is designed to assist individuals to build or focus on their motivation to change and is a skill that can be used to help clients understand the choices available to them so that they can better self-manage. You will need to be able to communicate effectively. Effective communication ensures the provision of accurate and appropriate care, facilitates clients participation in health decisions, and is essential in the care coordination process. It underpins a care coordinator s role in supporting clients to self-manage. Communication with the client s general practice is essential with all information including feedback about assessment and interventions. You will need to be empathetic to cultural and linguistic diversity. Understanding and addressing cultural diversity will assist you to provide culturally appropriate care that acknowledges and respects the integrity of each client. Culturally appropriate personcentred care supports individual s cultural, linguistic and spiritual needs in order to establish a meaningful therapeutic relationship. Culturally appropriate care necessitates an awareness of the cultural and religious factors that can influence the way clients respond to illness, ageing and health care. Further information www.carecoordination.com.au Primary Health Tasmania provides a comprehensive induction, training and support process. This support is ongoing with network forums, education and training opportunities. The regional program coordinators are responsible for contract implementation, management and compliance and have regular contact with commissioned organisations. 19

Resources Example tools of care coordination Care Coordination Program Client Centred Short Term Goals (to be left with client) Title: Family Name: First Names: Date of Birth / / Age: Timeframe Progress Identified concerns What I want to achieve? Who is Steps to get there/actions /Review towards this (including self-management) (management goals) responsible? date goal Care Coordination Program Client Centred Short Term Goals (to be left with client) Title: Family Name: First Names: Date of Birth / / Age: CCP Client Centred Short Term Goals July 2015 Page 1 of 2 Client Self Management (Symptoms) SYMPTOM ACTION PLAN Date completed: / / Date to be reviewed: / / Refer to the disease specific Action Plans in tool kit and attach copies Care Coordinator Tasks: Free text box Client Signature: Date: Care Coordinator name: Contact details: Date: CCP Client Centred Short Term Goals July 2015 Page 2 of 2 For further information on other care coordination tools refer to: www.carecoordination.com.au 20 Care Coordination Program Guidelines

Care coordination online learning platform For further information: www.carecoordination.com.au For further information: www.primaryhealthtas.com.au 21

These guidelines align with the Australian health priority areas and the following projects and references: Primary Health Tasmania s initiatives: Tas After Hours Tasmanian Health Pathways Tasmanian Health Directory Shared Transfer of Care One State, One Health System, Better Outcomes: Delivering Safe and Sustainable Clinical Services, Tasmanian Government White Paper June 2015 National Statement on Health Literacy, Australian Commission on Safety and Quality in Health Care, 2015 A Framework to Support Self-Management, Department of Health and Human Services, Tasmania, 2012 The Australian Privacy Principles (APPs), which are contained in schedule 1 of The Privacy Act 1988 The National Safety and Quality Health Services Standards, 2010 Standard 1 Safety and Quality in Health Service Organisations Standard 2 Partnering with Consumers Standard 6 Clinical Handover National Chronic Disease Strategy, 2006 (currently under review) 22 Care Coordination Program Guidelines

Care Coordination Program Services map for chronic disease and Aboriginal health Northern services 5 Primary Health Tasmania 2 Outreach services 6 General practices 1 Aged care facilities 1 Community organisation North West services 2 Primary Health Tasmania 1 Outreach services 4 General practices 1 Aged care facilities 2 Tasmanian Health Service 2 Community organisations Southern Services 2 Primary Health Tasmania 5 General practices 3 Aged care facilities 2 Community organisations Services across Tasmania 12 Primary Health Tasmania 3 Outreach Services 15 General Practices 5 Aged Care Facilities 2 Tasmanian Health Services 6 Community Organisations 23

Contact Primary Health Tasmania Level 4, 15 Victoria Street Hobart 1300 653 169 e info@primaryhealthtas.com.au www.primaryhealthtas.com.au