Care co-ordination – an antecedent to fragmentation in health care

A discussion on care navigation and care co-ordination is inextricably linked to the reality that healthcare is complex and fragmented. A range of factors contributes to this. These include increasing specialisation within the workforce, funding models with State and Federal delineation, professional demarcation, diverse business and operating models (e.g., corporate, standalone small business, public and private), professional boundaries and regulation. Moreover, the health system is largely predicated on the practice of individualised medicine, with the context/geography and the cultural norms of the services also coming starkly into play.

However, one core element underpinning fragmentation is time and volume-based funding of healthcare which disincentivises care co-ordination.  This is exacerbated in primary care settings. Along with increasing demand and patient complexity, there are expectations imposed on general practice by patients and providers in other parts of the health and social care systems to effectively co-ordinate care to improve patient outcomes. In parallel, general practice carries a high care burden due the ageing of the population and complexities of co-existing chronic conditions. While allied health professionals are remunerated through MBS to attend case conferences (in specific circumstances) this is not of itself care co-ordination and navigation and comes with its own barriers and challenges.

… one core element underpinning fragmentation is time and volume-based funding of healthcare which disincentivises care co-ordination.

Second only to time and volume-based funding models is the impact of social determinants. Health inequity and social determinants are drivers of fragmentation, impeding access to the healthcare pathways that are most appropriate to the individual patient. A patient’s capacity to navigate health care is dependent upon literacy, health and digital literacy, digital resources, and effective communication skill.  Notwithstanding a capacity to negotiate the patient/practitioner power imbalance where many people hold to the traditional view that they do not have the right to question their clinician. Financial and personal resources are another significant element, and the evidence is clear, marginalised people have a poorer health status and suffer the highest burden of disease.

…. general practice carries a high care burden due the ageing of the population and complexities of co-existing chronic conditions.

An associated phenomena is treatment burden, and it is often where health and social care are linked. Vulnerable populations, including but not limited to First Nations people, homeless people, culturally and linguistly diverse groups, and people who have frequented government mandated care may struggle to manage the priorities of day to day living, with few resources for self-care. Treatment burden recognises that is just too difficult to manage the challenges of accessing healthcare let alone navigating it, negotiating it, and understanding the maze of jargon and steps.  As noted above, health literacy is central to a person’s capacity to navigate the health system. Yet health literacy is anathema for those whose life circumstances are socially, economically, and geographically disadvantaged.

Health inequity and social determinants are drivers of fragmentation, impeding access to the healthcare pathways that are most appropriate to the individual patient

Fragmentation of the health care system is an antecedent for the creation of navigator roles and care co-ordination service delivery models in primary care.

An example of optimal care co-ordination is an Australian Government-funded program targeted toward Aboriginal people whose care is predominately delivered in mainstream General Practice. Integrated Team Care (ITC) provides care co-ordination with an emphasis on navigating access to specialist health services (enabling appointments, negotiating costs of care, transport, appointment follow up and assistance with treatment adherence), whilst simultaneously contributing to the social supports that are likely improve health outcomes. ITC also works with General Practice supporting culturally competent services as well as liaising with specialities on how to engage and empower First Nations people to be a partner in the provision of their care. ITC works with the person /patient at the centre in a culturally secure way, and as we know a person’s experience of care can lead to either positive or poorer outcomes.

With a focus on general practice managing large groups of marginalised people, WAPHA has implemented a Social Worker in General Practice program. In this example, social workers address any of the range of factors impacting the person’s health or well-being that would otherwise mitigate the benefit of GP care. The cohort includes people with mild mental illness who need assistance to access the right treatment modality, people with co-occurring alcohol or other drug issues who need assistance navigating social services and people resident in boarding houses needing housing support services. Whilst not necessarily care-co-ordination by some definitions this program directly links health and social care, enabling the person to access support through a navigation process, and by doing so, ensuring their ongoing engagement in primary care – where their care is best managed and delivered.

It is critical to note in these examples that while care co-ordination is a vital activity to help people navigate a pressured system, it is not predicated on a deficit model – people are active participants whose wishes are respected, and their voices heard. These examples epitomise person centred care and provide mechanisms for the individual to become more active in managing their own health.

These examples epitomise person centred care and provide mechanisms for the individual to become more active in managing their own health.

At a system level care co-ordination provides, or at least contributes to, value-based healthcare. The hidden costs of unplanned hospital readmissions, emergency department presentations and expensive treatments can be modified through effective care co-ordination. Rather than an additional cost to care it can improve system efficiency. Yet it is not funded as a core function in the time and volume focussed and activity-based approach that underpins the Australian health care system.  It is often incorrectly argued that care co-ordination is built into the existing funding models. However, people with the highest burden of disease, the highest emergency department presenters, are the same people who benefit from care co-ordination as demonstrated by ITC. Yet many do not have the opportunity to access this support.

… people with the highest burden of disease, the highest emergency department presenters, are the same people who benefit from care co-ordination

There are those who view care co-ordination as a band-aid for a complex healthcare system and hold hope that over time system-level reform will lessen the need for it. But at the same time, there are such diverse target groups and models of care co-ordination, some focussing on age as access criteria, others are disease specific, and they are developing in diverse settings delivered by paraprofessionals through to clinicians. So, as endeavours continue to be made to implement person-centred and integrated care it is evident that care co-ordination, with an eye on sustainability, is a vital element of the overall system. While we have health inequity and an increasingly complex health system, we will continue to require the bridge that can mitigate the effects of social determinants on a person’s health status.

Care co-ordination is this bridge.

About the author

Portrait of the authorLearne Dugginton Learne Durrington is the CEO of WA Primary Health Alliance. She brings to the role extensive experience in health and social services, this has stood her in good stead to achieve the purpose of the organisation that is improved access, equity in delivery of primary healthcare. Learne is a tireless advocate of joining up care to better meet people’s needs, and seeks to remind us of the privilege we are afforded in servicing the community at large.

Learne is a keen cyclist and a keen gardener to keep her sane and healthy!

References

Hippocrasy: How doctors are betraying their oath – Harris, I & Buchbinder, R, 2021

Integration and Continuity of primary care: polyclinics and alternatives: a patient-centred analysis of how organisation constrains care co-ordination – Sheaff, R; Halliday, J; Ovretveit, J. Health Services & Delivery Research, 2015

Navigation delivery models and roles of navigators in primary care: a scoping literature review – Carter, N; Valaitis, R.K. et all. BMC Health Serv Res 18, 2018

Realising the potential of primary health care – OECD Health Policy Series Paris 2020