Our flagship program is an integrated care coordination program delivered by clinicians, to improve patient outcomes and reduce costs to the health system.
All our programs are delivered by clinically trained, community-based care coordinators who are supported by a team of customer care consultants. Care coordinators meet with participants, complete assessments and work in partnership with the participant’s GP to develop care plans. They also liaise and coordinate the services required to meet the goals of the participants.
Customer care consultants provide administrative support for non-clinical activities and work closely with care coordinators to ensure participants are on track to achieve their goals.
We take a client-centred approach to care coordination which means care plans are designed in consultation with program participants and their GPs, taking into account clinical risks and the participant’s personal goals and their preferences for service delivery.
We meet participants in their own homes to establish a connection, gaining important insights into their home and broader psychosocial environment, their current supports, and any risks that may be present. Care coordination plans target the evidence-based interventions that are most likely to make a difference, and which are most supported by the participant and their GP.
Throughout the process, participant needs and progress are regularly monitored to identify any changes or concerns. If there’s a significant change to the participant’s health and wellbeing the care plan will be reviewed, with the option for the participant to be moved to a higher level of care.
Alternatively, if a participant makes quick progress towards their goals, and is managing independently then they will be discharged from the program earlier than anticipated, rather than continuing until the original discharge date.
Please feel free to contact us if you want to speak to someone about our services in more detail.