B5: Coordinating care

Download page Download PDF
Key point

Key Points

  • People with co-occurring mental health and AOD use disorders often present to treatment with various issues that need to be addressed during the course of treatment (e.g., physical health, housing, employment, education and training, legal, and family issues).
  • Evidence has linked coordinated care with improved treatment outcomes. Specifically, the coordination of health responses into a cohesive approach has been found to prolong client retention, increase treatment satisfaction, improve quality of life, and increase the use of community-based services.
  • Although coordinated care may be facilitated by a 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.
  • The principles of coordinated care can be adopted into referrals and discharge practices, with an emphasis placed on the importance of communication, consultation, and interagency support.
  • AOD services and AOD workers should develop links with a range of local services and engage them in clients’ treatment where appropriate.
  • Discharge planning in close consultation with the client is integral to the treatment process.

There has been increased recognition of the need for a holistic approach to health care, which is better able to incorporate services that reflect a person’s need for housing, employment, education, training, community, justice, and other support services in the delivery of appropriate mental health care [583, 584]. As described in Chapter B1 and Chapter B3, people with co-occurring mental health and AOD use disorders often present to treatment with numerous additional issues that need to be addressed during the course of treatment, including physical health, housing, employment, education and training, legal, and family issues. These issues can often be interrelated, such as difficulty obtaining employment due to a lack of secure housing and/or childcare [585]. It can be extremely difficult for a person to maintain progress in relation to their mental health or AOD use if they do not know where they are going to live, or how they are going to feed themselves or their family. Therefore, addressing these fundamental issues as part of treatment is essential, and is also in line with the approach of ‘treating the person, not the illness’ [9, 389, 586].

Engaging with other services is best thought of as a consultative process. GPs are of particular importance as, in many cases, they have a prior relationship with the client, and they are often the client’s only consistent form of contact with the health care system. Most importantly, consultation with other services should be based on the most essential and desired needs of the client. Although some clients may benefit from treatment by mental health professionals, they may not be ready for such treatment, and it should not be forced at the risk of alienating them (unless they pose a risk to themselves or others). MI (discussed in Appendix E) can help clients gain willingness to receive treatment, but others may not be ready even after such attempts are made. Each client is different and will manage their situation differently – the key is to support and guide clients and facilitate treatment and access to services as required.

Peer workers also play an important role in supporting clients with AOD and mental health conditions. Peer support can facilitate program engagement, and the delivery of programs by peers has been found to enhance treatment outcomes [587]. Data from qualitative interviews conducted among people attending treatment for their co-occurring disorders also suggests that peer support provides opportunities for community integration, aids in building social confidence, provides a safe space, improves feelings of being accepted, and helps people to not feel alone [124, 125, 588]. Figure 15 illustrates some of the services that may need to be incorporated into a coordinated approach to clinical care.

Figure 15: Services that AOD workers may need to engage in client care

Coordinated care increases the likelihood that clients will receive specialised assistance where it is needed and facilitates client engagement in treatment. There is evidence to suggest that care coordination is effective in increasing treatment engagement and retention, increasing treatment satisfaction, improving quality of life, increasing the use of community-based services, and decreasing the cost of healthcare [589–595]. Treatment retention has been consistently associated with better treatment outcomes among people with AOD use disorders [594, 596–598].

Evidence suggests that clients place a high degree of importance on interagency cooperation in terms of coordinated care and case management, with higher levels of service integration associated with clients reporting that their needs have been better met [599]. Clients have described the optimal service as one that delivers a coordinated, holistic approach, where staff are aware of the needs of clients and are proactive in following them up, and work with other services to deliver seamless care [599]. Superior treatment outcomes have similarly been associated with coordinated care when there is frequent in-person contact, close interaction between primary care providers and case managers, and culturally responsive practices [600, 601]. Conversely, a lack of coordinated care and service integration can have a negative impact on clients. Distress may arise from the need for clients to continuously retell upsetting stories or rehash details to multiple service providers. Confusion may also result from having a number of different health care workers involved in the care of one person without coordination [599].

Despite the need for integrated service approaches to respond to complex problems, the practical implementation may not be so straight-forward. The primary challenge may lie in structural barriers, service silos, and older models of mental health support, which prevent the effective provision of holistic care [602]. In turn, many people with mental health conditions experience a lack of coordinated care, or service integration, and consequently fall ‘between the gaps’ [102, 602].

Load Google CDN's jQuery, with a protocol relative URL and local fallback -->