Improving care coordination for people in community rehabilitation

Miss Jane Symons1, Mrs Julie Jamison1, Mrs Jane Dening1

1Community Rehabilitation Unit, Hobart, Australia

This qualitative research project explored staff perceptions of and actions in doing client care coordination in community rehabilitation. Care coordination is a set of tasks that aim to integrate and streamline client care, with a focus on the client’s rehabilitation goals in this setting. The impact of a current quality improvement project on interprofessional care coordination was also explored.

Interviews and observations were completed over 12 months, collecting 26 hours of information from 13 key participants and 22 additional participants. Results highlighted the following concepts in relation to both care coordination and change. Outcomes were effectiveness and efficiency. Approaches used were client centred and holistic care, with flexibility versus consistency of approach required. Teamwork utilised communication, coordination, collaboration and consideration of differences amongst people. These concepts, along side resources, were either barriers or facilitators depending on their presence. Access to people with clinical reasoning skills, knowledge of the service, and a positive attitude were enablers. Lastly, communication tools, transport and space were required facilities.

Over the course of data collection, a reduction in some barriers and strengthening of some enablers was noted, but overall further time and energy was required for continued change.  Findings sat within the framework and context often seen in interprofessional workplaces (Canadian Interprofessional Health Collaborative, 2010).  This suggests that as well as focussing on processes for care coordination and change, we must review our skills in interprofessional competence, for maximum benefit to the service and for clients in returning to independence or maintaining function.

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