Innovative models of health care are not only focused on providing physical or mental health care, but seek to incorporate services that are reflective of a person’s broader needs (e.g., employment, housing, education, training, community, and justice health services) [603–605]. The actual definition of coordinated care can vary between services, and can include case management, collaborative care, shared care, team coordination, and multidisciplinary care. In practice, coordinated care should involve the coordinated delivery of individual services across multiple sectors, which is perceived as a seamless service system by clients, and results in overall improved client outcomes [102, 599, 602, 605, 606]. Despite differences in terminologies, the core elements remain the same. Figure 16 illustrates the core elements of care coordination.
Although coordinated care is facilitated by an identified coordinator or case manager, they are not expected to provide all of the necessary services themselves, but rather refer to, and manage the engagement of, appropriate services [389]. The challenge for a holistic health care approach to co-occurring conditions is in the active engagement of multiple services and service providers, with a mixture of professional and non-professional support [605, 607]. AOD workers in particular are in primary positions to coordinate care and incorporate the many services that reflect the particular needs of clients, to deliver the best quality mental health services. Box 13 illustrates the continuation of case study K, following Con’s story after one of his mental health workers suspected Con was hearing voices.
Figure 16: Core elements of coordinated care
Adapted from McDonald et al. [608], Ehrlich et al. [609], Brown et al. [610], and NSW Mental Health Coordinating Council [611].
Box 13: Case study K: Managing co-occurring physical, mental, and AOD use disorders: Con’s story continued
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Case study K: Con’s story continued
It was apparent to the mental health outreach workers that Con was experiencing a relapse of symptoms of psychosis, and Con was readmitted to an inpatient mental health unit. During Con’s admission, the social worker assigned to him applied for a National Disability Insurance Scheme (NDIS) package to provide Con with an increased level of support to assist with maintaining his living in the community. The increase in support provided enough for a cleaner and support worker who visited Con every day and took him to his medical appointments, all of which was overseen by a care coordinator. With the additional support, Con was able to reduce his drinking and keep his house clean. Con’s support team were also able to ensure his nutritional needs were being met and provided additional social contact by taking him to and from the shops. Con’s community mental health team continued to visit him and manage his psychotic disorder.
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Key Points
- There is a need for AOD workers to place more emphasis on physical health as a priority (bearing in mind the years of life lost in this population).
- Once the health needs of clients are recognised, holistic health care interventions such as physical activity, smoking cessation, healthy eating, and healthy sleep patterns can follow. The importance of adherence with physical health medications (e.g., blood pressure and diabetes medications) should also be emphasised.
- Many clients may require more assertive follow-up, including long-term practical support (e.g., phone or text reminders, or someone to accompany the client to appointments).
- Communication between AOD workers, mental health services, and GPs is essential.