Coordinated Care Implementation

Why do co‑morbid patients suffering heart failure and COPD drive the highest number of avoidable emergency department (ED) admissions in Australia? Or more importantly, what does it take to really make coordinated care work in the primary care setting?

Recent research from the UK, Scandinavia and the US provides answers to these key questions. It indicates that health care for these patients can be better coordinated to substantially reduce ED presentations and re‑admissions.

Similarly, coordinated care has the potential to improve outcomes and reduce per‑capita costs for people suffering complications from other chronic diseases such as diabetes Type II, hypertension and asthma.

Without new models of coordinated care implementation, escalating hospitalisations and per‑capita costs driven by ever increasing rates of chronic disease and mental illness will become unsustainable.

What we do

We draw on our practical experience, and the experience of our international partners, in coordinated care gained in Australia, Asia and Scandinavia to help Primary Health Networks make the fundamental shifts necessary to deliver results in coordinated care in the GP and allied health setting.

Our team is experienced in addressing the complex issues arising from fragmented clinical pathways, poorly implemented eHealth systems and poor engagement of GPs, Community Nursing, and Allied Health services.

We help our clients in six key areas to design and implement coordinated care programs:

1. Clarify Triple Aims
2. Target the right patient cohort/population
3. Design a Best Practice Coordinated Care model
4. Ensure step-change improvements in patient self care
5. Implement an enabling eHealth system
6. Introduce new flexible funding and incentive models.