Care coordination for vulnerable families in the Sydney Local Health District: what works for whom, in what circumstances, and why?

Introduction: Healthy Homes and Neighbourhoods HHAN is an integrated care program in inner west Sydney currently supporting over 150 families. The initiative aims to provide integrated care via long-term care-coordination for vulnerable families with complex health or social care needs. This research aims to determine for whom, when and why the care coordination component of HHAN works, and establish the reported outcomes for clients, care coordinators, and partner organisations.

Theory/Methods: This project utilises critical realist methodology to undertake a qualitative evaluation of the care coordination model. Interviews involved purposive sampling to identify thirty participants including a mixture of HHAN clients, HHAN employees, and stakeholders or other service providers. In-depth semi-structured interviews were audio-recorded, transcribed and coded using NVivo.

Results: Analysis indicates that the care coordination model has a positive impact on clients’ sense of independence, self-awareness and outlook. Trust and favourable interpersonal relations were identified as the major underlying mechanisms for a successful care coordination working relationship. The identified modes of intervention facilitating positive client outcomes included accessibility, flexibility, and service navigation. Persistent siloes in health and systemic resistance to collaboration was seen to hinder effective care delivery.

Discussion: There is a need to appreciate the negative impact the complex and siloed health system can have on vulnerable families. This study suggests that a care coordination model can assist clients to navigate that system, and be beneficial in empowering and engaging them healthcare. Successful implementation of care coordination requires flexible program design, as well as experienced and skilled clinicians fulfilling the care coordinator role.

Conclusion: Preliminary analysis identifies care coordination as an effective method for creating an integrated environment allowing clients to feel empowered to better manage their individual health and social needs.

Lessons learned: A care coordinator role is effective in integrating health care services and improving individual client outcomes, however the role often involves aspects of case management, particularly in the early stages of intervention.

Limitations: Whether the findings are applicable to other integrated care programs is unknown. HHAN clients were only interviewed if their medical and social situation was relatively stable potentially limiting the variety of perspectives obtained.

Suggestions for future research: A comprehensive evaluation of HHAN will also involve the exploration of quantitative data to further assess the impact on health and social outcomes. Ongoing mixed-methods evaluation of the program will continue to assess medium to long-term client and family outcomes.