1. Care Coordination Working together - the team approach
Stuart Mobsby
Nurse Practitioner
Primary Health Care – West Arnhem
Top End Health Service

2. What is care coordination?
‘Care coordination’ is a person-centred, assessment-based, interdisciplinary approach to integrating health care and social support services in a cost- effective manner in which an individual’s needs and preferences are assessed, a comprehensive care plan is developed, and services are managed and monitored by an evidence-based process which typically involves a designated lead care coordinator.
National Coalition on Care Coordination 2011
Primary Health Care - West Arnhem - Top End Health Service

3. Why do we coordinate care?
A fragmented healthcare system with ineffective communication among healthcare professionals poses challenges to delivery of care that can yield sub-optimal health outcomes in a high-risk population. Payne, 2012
Primary Health Care - West Arnhem - Top End Health Service

4. Who coordinates care? Patient Health Professional System
Primary Health Care - West Arnhem - Top End Health Service

5. The team approach Rural/Remote Medical Practitioners
Primary Health Care Nurse, including PHCM
Aboriginal Health Practitioners
Aboriginal Community Workers
Nurse Practitioner
Public Health Co-ordinator
Outreach Team – Preventable Chronic Conditions Educator, Dietitian, Outreach manager
Primary Health Care - West Arnhem - Top End Health Service

6. Aims of the team approach
Patient advocacy
Set plans, goals and priorities
Improve communication
Support inter-disciplinary education
Clarification of roles and responsibilities
To support specialist and visiting services
Document coordination of care
Sustainability
Primary Health Care - West Arnhem - Top End Health Service

7. Nurse Practitioner Clinical Education Research Leadership
Primary Health Care - West Arnhem - Top End Health Service

8. Planning for the future
Continue to develop the team approach
Involve a CQI approach to developing plans
Care coordination to be integrated across health service
Primary Health Care - West Arnhem - Top End Health Service

9. References
National Coalition on Care Coordination (2011) Implementing Care Coordination in the Patient Protection and Affordable Care Act, Policy Brief, viewed 25th October 2016, ation%20in%20the%20Patient%20Protection%20and%20Affordable%20Care %20Act.pdf
Payne, G.M., 2012, ‘We can do better: with care coordination’, Nephrology Nursing Journal, vol 39(4) pp
Primary Health Care West Arnhem - Top End Health Service