Health conditions

Care coordination for mental health

What is care coordination?

Care coordination is the process of helping a person with a mental illness to access a range of different services in a way that helps them get better, and works towards their recovery. It involves interactions between different clinicians and health care providers, the individual, their carers, family members and other significant persons.

The goal of care coordination is to improve the health and functioning of people with mental health problems. It is especially helpful for mental health consumers who have complex mental and physical health care needs, living in long-term care settings. These individuals are particularly at risk of ‘falling through the cracks’ because they are involved with multiple agencies and individuals who are helping to address their care needs.  

Care coordination may include working with multidisciplinary teams, psychosocial support providers and self-management, in addition to clinical treatment.

A Care Coordinator is a person who has the responsibility of coordinating, facilitating and integrating mental health treatment, care and support, which is tailored to meet the specific needs of individual consumers. The Care Coordinator may work from within the specialist Mental Health Service or from a Community Managed Organisation or primary health care service.

Things that individuals with complex needs, and their families and carers, can do to promote care coordination

  • Talk to your case manager, clinician and/or support worker about your unmet needs.
  • Ask questions: learn who will be informed of any changes in your care or that of your loved one.
  • Recognise that caring for an individual who has challenging mental health issues can be demanding on the individual, their carers, families, supporters and clinicians. 
  • Organise respite when needed.
  • Ensure you know the names of the people involved in your care or that of your loved one.
  • Double-check all appointment times and places.
  • Ask for information and appointment details in writing – copies of forms, letters or emails.
  • Find out information about mental disorder, and learn about the sufferer’s journey, so that you are aware and can plan for the next stage.
  • Find out what organisation or agencies are involved in your care or that of your loved one, so you know who to speak to if anything goes wrong. 

Guiding principles of good care coordination

Carers providing good care coordination should demonstrate the following qualities:

  • is recovery focused
  • is person centred
  • respects the individual’s values
  • builds therapeutic relationships which address the individual’s holistic needs
  • works in partnership with all care stakeholders
  • provides proactive family and carer involvement
  • is socially inclusive
  • possesses an evidence based coordinated service delivery
  • a sense of ownership and accountability for all those involved in the individual’s care.

Where to get help

If you think you or your loved one is not receiving properly coordinated mental health care in the public system, you should first speak to your case manager. If there is no current case manager, you can contact the relevant public health service below:


Acknowledgements

Clinical Research Centre


This publication is provided for education and information purposes only. It is not a substitute for professional medical care. Information about a therapy, service, product or treatment does not imply endorsement and is not intended to replace advice from your healthcare professional. Readers should note that over time currency and completeness of the information may change. All users should seek advice from a qualified healthcare professional for a diagnosis and answers to their medical questions.

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