Locality Care Coordinator supporting multiagency proactive care

Background: People and whānau with complex health and social conditions often require support and care from multiple health and social care providers simultaneously to optimise their trajectory.  For some, the greater the complexity of their health, the greater the likelihood that numerous providers and agencies will be part of their care team. This describes a proactive approach to support people with these complexities.

Approach: Our focus has been to strengthen the provision of coordinated care to ensure that all provider input is connected, aligned and proactive.  To achieve this, we resourced three dedicated roles, based in our primary care, called ‘Locality Care Coordinators’ (LCCs). They become involved when the level of health and social complexity requires coordinated inter-disciplinary efforts across an extended virtual team. They leverage relationships across the local provider networks and develop a common and proactive care approach.

The general methodology was developed and based on feedback and co-design processes with community members, people with lived experience, whānau and patients. We heard that people want services to work strongly together, they don’t want to retell their story multiple times, and they would like support early, before they hit a crisis. 

Sponsored by health system leaders and consumer advisors, they guide operational managers to establish multi-disciplinary and multi-agency meetings, or huddles, made up of a combination of clinicians, service coordinators and key workers. The focus is to identify needs not currently being met and agree the proactive action to take. The team works collaboratively with the common understanding that people benefit from a joined-up relational approach that is culturally responsive, disability aware, equity focused, strengths based, person and whānau centred.

Results: Three areas of focus led and coordinated by LCCs include:

1.Hei Pa Harakeke | First 2000 Days – Local MDT meetings which are a fully consented process. Early signs that may contribute to whānau stress or risk of attachment can be discussed with the team and is open to anyone working with whānau; and is open to any provider. This approach reduces:

• referrals to access specialist advice,
• wait list, and
• child protection involvement.

2.Care@Home – Local MDT meetings are held to proactively follow up with people who attended emergency departments (ED) and left prior to treatment or were considered high risk by ED of falling through a gap or re-presenting. Out of the total presentations, there 4% were in this cohort. Of these:

• 16% re-presented to ED within 7 days.
• 35% of the total group and 42% of non-NZ European had ‘value added’.

3.Police and MH&A – Cross agency MDTs are held involving Police, MH&A, ED, primary care, Hauora Māori NGO. The aim is to gain a better understanding of what happened and identify opportunities to prevent a repeat call-out and then trigger a proactive action.

Implications: Key aspects that ensure effectiveness of these integrated LCC-led MDT align well with the nine pillars of integrated care. Actions are themed and feedback captured which informs improvement activities and more collaborative opportunities.