The aim of a Care Coordination program by an external contractor is to provide an individualised, multidisciplinary approach to the care of patients with chronic and complex health conditions to improve the patient’s ability to self manage their chronic conditions - the same aim as if you were providing the service in-house.

Care coordination by an external coordinator usually occurs when the practice does not have the resources in-house. Care Coordination must be patient centric and GP-driven. The program must be conducted by a competent and highly trained health professional with primary health care experience who will act as a link between the various members of the patient’s care team.

• GP and patient have access to an experienced nurse who coordinates community and allied health service for the most complex patients
• Coordinated discharge planning for patients admitted to hospital
• Decreased hospital admissions for high users
• Better communication between general practice and hospitals
• Patients feel better about the level and quality of care they receive
• Care coordinators have a good relationship with domiciliary services
• Able to monitor ongoing needs of patients

In some cases where the local division of general practice offers a care coordination program, there may be funds available to purchase services for patients to address risk factors or prevent hospital admissions.

GPpartners offer Team Care Coordination to practices in our catchment.

The process involves five steps:

• Engagement of an external contractor
• Identification of potential patients
• Consent and Assessment of patients
• Collaboration with service providers and implementation of services for each patient
• Review and evaluation of patients’ needs

There are many things to be considered here when engaging an external contractor.

 

• The contractor’s scope of duties needs to be outlined both for the contractor and the practice so that each has a very good understanding of what is expected on both sides.
• Remuneration for the contractor must be negotiated. There are many options for remuneration from an hourly rate or a fixed amount per item number, plus or minus a fee (fixed or variable) for additional expenses or incentive payments.
• Consideration should be given to public liability / professional indemnity insurance.
• It is essential that a contractor agreement is drawn up and signed by both parties covering the issues outlined above and listing the deliverables and the obligations of both parties.

Further information about this can be gained by talking to practices that have used an external contractor. Contact could be made with your local division of general practice who may be able to put you in contact with one of these practices or could provide you with the information you are seeking.

The GP and the practice staff are responsible for the identification of potential patients for the program, however the Care Coordinator could be called upon to assist and support GPs and staff in identifying patients. 

There are a number of ways to identify patients such as by extracting data from practice software to develop lists of patients with specific chronic diseases such as diabetes or coronary heart disease. The practice software can also identify which patients have already had a GP Management Plan (GPMP) or Team Care Arrangement (TCA) or reviews in place. These lists can then be reviewed by the GP to identify those who would be suitable for care coordination or further follow up.

Once identified, the patient may be contacted by the Care Coordinator. The preferred method of contact may vary between practices. In some cases, the GP may prefer to make contact with each patient individually and explain what is happening or they may be happy for the Care Coordinator to make that first contact. In other practices, the practice staff will contact the patient to set up an appointment with the Care Coordinator.  

A phone script or letter template can be utilised by the practice staff to assist with this. Ideally, appointment setting should be done by practice staff as it is better use of time and resources. 

Regardless of how the patient is first contacted, the Care Coordinator will need to meet each patient either in the practice or on a home visit, if necessary. The first contact with the patient can take time and a minimum of one hour is allocated to each patient for this. This appointment is where consent takes place.

At the first appointment, the Care Coordinator, after having ascertained the patient’s eligibility for a GP Management Plan (Item 721) and a Team Care Arrangement (Item 723), will explain the process and gain the patient’s consent to participate.

The Care Coordinator may use a consent checklist / form with the patient that the patient may be asked to sign. If there is any doubt about the patient’s capacity to provide informed consent the Care Coordinator should discuss this with the patient’s carer or GP. While it is mandatory to gain consent, verbal consent is acceptable. It should always be noted in the patient’s file that consent has been given.

The assessment will most likely occur at the time of consent. It would be prudent prior to this appointment for the Care Coordinator to obtain a copy of the patient’s health summary and establish if the patient has a GP Management Plan and Team Care Arrangement or if the patient has had a recent Health Assessment. In most cases, the patient will not have had these done if there has been no nurse in the practice to do it. Occasionally, the GP may have done one already.  

This health summary provides information regarding the patient. Using this document and the patient’s file and by interviewing the patient, the Care Coordinator conducts an assessment of the patient’s health and care needs using an Assessment Tool.

The Assessment Tool should cover such areas as:

Communication	Transport	Medication Management
Carer information	Podiatry	Sleep
Cognition	Nutrition / Hydration	Mobility
Mental Health	Pain	Socialisation
Elimination	Independence with ADLs	Personal safety
Respiratory

Much information is gained from this assessment and it is essential that this information is passed on to the GP in the form of a management plan and often will add value to the patient care plan if already developed by the GP.

Once the GP and Care Coordinator have established what services are required for the patient, it is critical that they communicate their findings to the rest of the patient’s care team. This is where the Care Coordinator’s experience proves invaluable in gaining written or verbal feedback from the relevant health and care providers. For a listing of where the patient can be referred, see Care Coordination for Nurses in General Practice.  

The Care Coordinator’s role should be, in consultation with the GP, to send off the referrals, collaborate with service providers, document into the patient’s file, and set up an appointment for review.

Reviews normally occur at six months but if clinically indicated can be done from three months, if necessary. Each patient’s GP Management Plan and Team Care Arrangement (TCA), if applicable, will be reviewed by the Care Coordinator prior to meeting with the GP. The TCA review will involve communication with the patient’s care team as well as a repeat assessment using the Assessment Tool.

It will be the role of the Care Coordinator, in most instances, to assist the GP with the development of a GP Management Plan (Item 721) and where appropriate, a Team Care Arrangement (Item 723). With a clear plan as to the requirements for the individual patient, the Care Coordinator will use his / her knowledge of local primary health care services to connect the patient to the most appropriate services. 

A comprehensive list of local services should be developed, which may be maintained by the Care Coordinator or practice staff. The Care Coordinator, in collaboration with the GP, will consider the patient’s individual circumstances and resources in deciding on the best approach to accessing the services required.

Access options include:

1. Enhanced Primary Care Allied Health Services

When the patient has a GPMP and TCA in place, they are entitled to access 5 x Medicare subsidised allied health services per calendar year ( www.health.gov.au/epc ), or where appropriate, dental services under Medicare and diabetes group education sessions.

2. Private Health Insurance

Patients with private health insurance may be able to use their cover to pay for allied health visits, etcetera. The Care Coordinator may need to contact the insurance company on behalf of the patient to establish the patient’s entitlements under their policy.

3. Self-funding

The patient can be asked to contribute in full or part to the cost of services required depending on the resources they have available.

4. Public health system (through HACC)

The public health system community services are available, however, there is often a significant waiting list for services due to the demand for these services. The Care Coordinator will assess the risk to the patient when deciding to place them on a waiting list or pursue other options to access the service required.

5. Brokerage funds (if going through a division of general practice that provides care coordination services)

Care Coordination programs may have funds available to purchase services or equipment required by the patient to address risk factors or avoid a hospital admission. These funds may be used to pay the “gap” charged by private providers, get patients started on a treatment program provided privately while on a public waiting list, or to enrol patients in chronic condition self-management courses.



Depending on the Care Coordinator’s role, they may follow the patient’s progress through any hospitalisations that occur and may assist with discharge planning when the need arises. The Care Coordinator also provides a value add service by promoting and expanding the GP’s and practice’s knowledge base of types of services available to patients in the general practice.

The Care Coordinator can do as little or as much as is negotiated with them by the practice management.

During the process of arranging the services, and once the services are in place, the Care Coordinator will communicate by telephone, fax or email with the patient’s GP and other care team members. The Care Coordinator will also be in close contact with the patient during this time to ensure the arrangements are acceptable to the patient and the appointments are kept.

While there is some autonomy, the Care Coordinator maintains all necessary consultation with the GP and ensures timely and relevant feedback is provided.