Table of contents
- Executive summary
- Acronyms and abbreviations
- Introduction
- Examples of care coordination in action within the Stepped Care Model
- Implementing stepped care in general practice
- Using the stepped care services in your community
- Using the Better Access initiative, MHTPs, CCMPs and the IAR-DST in stepped care
- Empowering your consumer and carer
- Stepped care for specific populations
- Stepped care and telehealth
- Stepped care in rural and remote communities
- Setting goals and measuring outcomes
- GP education and training for stepped care
- Useful resources
- References
- Disclaimer
- Recommended citation
- Executive summary
- Acronyms and abbreviations
- Introduction
- Examples of care coordination in action within the Stepped Care Model
- Implementing stepped care in general practice
- Using the stepped care services in your community
- Using the Better Access initiative, MHTPs, CCMPs and the IAR-DST in stepped care
- Empowering your consumer and carer
- Stepped care for specific populations
- Stepped care and telehealth
- Stepped care in rural and remote communities
- Setting goals and measuring outcomes
- GP education and training for stepped care
- Useful resources
- References
- Disclaimer
- Recommended citation
Examples of care coordination in action within the Stepped Care Model
The following examples show how GPs can coordinate a consumer’s care while using the Stepped Care Model. Note that these in no way provide a full picture of how coordination can work.
Care coordination
- A child has learning disabilities and attention deficit hyperactivity disorder (ADHD) that significantly affect their schooling and family life. The child attends a public paediatrician, a children and youth mental health service, and an NDIS service. The child’s family is somewhat chaotic and the child continues to miss appointments. The child’s GP refers to PHN-commissioned stepped care services for care coordination.
- An Aboriginal man presents with depression. The GP creates a Social and Emotional Wellbeing template and works with the consumer to identify if psychological treatment is the best option for them. Recognising the importance of culturally safe, community-led care, the GP also works with the consumer to identify local cultural supports and refers to PHN-commissioned stepped care services, which may include care coordination in partnership with ACCHOs or Aboriginal Health Workers (AHWs).
- A young woman with an eating disorder and anxiety is seeing a private psychologist under an Eating Disorder Treatment Plan (EDTP), as well as a dietitian, and intermittently attends the local hospital ED during crises. Communication between providers is limited, and there is no clear relapse plan. The GP refers to PHN-commissioned stepped care services for care coordination to align providers, clarify roles, develop a shared care plan and establish early warning and escalation pathways.
- An older man with chronic pain, depression and social isolation sees his GP regularly and has multiple medical specialists. He declines referral to psychology due to perceived stigma, but reports worsening mood and poor sleep. The GP links him with low-intensity psychological support, community social groups and pain self-management programs, while ensuring communication between services.