PRINCIPLE 5: Care coordination

PRINCIPLE 5: Care coordination

Care coordination is the responsibility of every professional, both clinical and non-clinical, who works with patients, their families and carers.

Seamless care coordination is essential for patients to successfully navigate the complex health system. Care coordination is a comprehensive approach to achieving continuity of care for patients. It aims to ensure care is delivered in a systematic, connected and timely way that promotes efficiency and reduces the risk of duplication and over-servicing to meet the medical and personal needs of patients.

Care coordination includes:

  • proactive and timely communication with patients, their families and carers
  • treatment plans, survivorship care plans and/or advance care directives
  • coordinated appointments to ensure timely diagnosis, treatment and survivorship care
  • appropriate tests and results being available to the treating team so treatment decisions can be made
  • medical records being available to all members of the treating team and at scheduled appointments
  • translation or interpreter services arranged if the patient/carer is from a non-English- speaking background or has difficulty communicating due to a physical disability
  • practical support such as transport, accommodation, advance care planning and financial support
  • referral and access to supportive care
  • access to clinical trials
  • access to telehealth for people in rural and remote areas and for managing vulnerable patients.

Care coordination brings together different health professionals, teams and health services. It also encompasses MDMs, multidisciplinary assessment clinics, supportive care screening and assessment, referral practices, data collection, common protocols, information for patients and individual clinical treatment.

Care coordination should cross the acute and primary care interface and should aim to achieve consistency of care through clear communication, linkages and collaborative integrated care planning.

Care coordination can be facilitated through electronic health record management such as My Health Record. My Health Record is a secure online database that helps with data collection and care coordination (My Health Record 2019).

Formal care coordination through appointed care coordinators plays an important role in managing and supporting patients through the health system. The availability of dedicated care coordinators varies across states and territories according to the complexity of care required and local service capacity and resourcing.