Team Care Coordination aims to improve the health and wellbeing of patients with chronic and complex medical conditions through a coordinated team approach.

Community nurses (Team Care Coordinators) work closely with GPs and other health care providers to plan and manage the services required by eligible patients. Our Team Care Coordinators work with doctors to assess, plan and monitor their patient's health care and other care services they may need.

This management can include linking patients with community and allied health services such as home help, exercise programs and physiotherapy, to help them maintain or improve their quality of life.

Team Care Coordination also uses a secure electronic health record system to support management of these patients. The Health Record eXchange system is used by the GP and Team Care Coordinator to share essential health information with others involved in patient care, e.g. hospitals and allied health services.

Team Care Coordination is available to the benefit of both public and private patients who have chronic or complex conditions. Funding from both Queensland Health and Medibank Private Health Insurance will enable up to 1,000 people to be enrolled in Team Care Coordination in the first instance.

Benefits 

• GP and patient have access to an experienced community nurse. 
• Coordination of community and allied health service for the most complex patients. 
• Coordinated discharge planning for patients admitted to hospital. 
• Decreased hospital admissions for high users. 
• Funds to purchase services for patients to address risk factors or prevent hospital admissions. 
• Better communication between general practice and hospitals. 
• Patients feel better about the level and quality of care they receive.

GPpartners has more than 11 years of experience in service coordination trials. Research data from these trials has shown that service coordination: 

• improved patient health outcomes 
• decreased hospital utilisation for chronic and complex patients by an average of 20% 
• resulted in higher levels of patient satisfaction regarding the health system 
• improved patients’ timeliness and frequency of access to services 
• increased patients’ sense of empowerment and personal responsibility for their health.

For a brief summary of the results of our previous coordinated care trial, Team Care Health II click here.

For more information contact the team. Download our GP infosheet.

Last update: 22 May 2009