|Implemented in this survey?|
The Coordinated Care Trials are regional projects to test whether multi-disciplinary care planning and service coordination leads to improved health and well-being for people with chronic conditions or complex care needs. Some also involve ?funds pooling? between Commonwealth and State/Territory programs to provide funding flexibility for this coordinated approach to service delivery. Following a first round of 13 trials (1997-2000) there are now five second round trials.
The purpose of the Coordinated Care Trials is to test whether multi-disciplinary care planning and service coordination leads to improved health and well-being for people with chronic health
conditions or complex care needs. Funds pooling between Commonwealth and State/Territory programs is also being trialed as a means of providing funding flexibility to support this coordinated
approach to service delivery. There are currently (April 2004) five second round trials under way which began in late 2002 and are planned to run for three years in total. Two of the
second round trials are based in Aboriginal communities, with the broader objectives of improving the health of the communities and increasing community understanding and control of health and
related services. These trials follow an original 13 first round trials (four Aboriginal, nine general) which ran from June 1997 until 2000.
For many people with chronic and complex care needs, care is provided by a number of quite separate service providers and, in Australia, these services are typically funded by different levels of government. Often the result is that people receive the care they can get rather than the care they need. The Trials seek to provide the right care at the right time. The full definition of coordinated care - the 'intervention' being tested by these trials - is:
"The explicit process of planning and organising the provision of services through pooling of funds, within current resource levels, and the development of agreed individual care plans for people who have difficulty accessing appropriate services and/or self-managing their care needs over a long period of time" (p.8, The Australian Coordinated Care Trials Background and Trial Descriptions, Commonwealth Department of Health and Aged Care1999). The Aboriginal trials have broader, more community-focused aims and service improvement strategies.
The coordinated care trials broadly seek to test whether an "explicit process of planning and organising the provision of services through pooling of funds ... and the development of agreed individual care plans for people who have difficulty accessing appropriate services and/or self-managing their care needs over a long period of time" leads to better health outcomes within existing resources. The Aboriginal trials have broader, more community-focused aims and service improvement strategies.
Ultimate incentives for the federal government include better health outcomes for no or little extra public expenditure.
For local institutional participants - particularly the designated fundholders - there may be scope to use any efficiency savings resulting from care coordination (but this cannot be confirmed)
People with chronic conditions and complex health needs, General Practitioners
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
The development of coordinated care trials is a response to both the complex and multiple needs of particular groups of people, and the poor coordination of care both across health services and
between health and other support services. The five current trials represent a second round of trials, following the 13 round one trials that ran from June 1997 to December 1999 or early
2000. The current trials began in late 2002 and include three based within Aboriginal communities.
From the policy perspective the central premise of the original trials was "that better coordination of the care of people with chronic or complex needs would reduce hospitalisation, and the savings could cover the costs of coordination" (Esterman & Ben-Tovim, Med J of Aus 2002 Vol.177 pp.469-470). They were thus intended to improve the health and well-being of people with chronic conditions and complex care needs without extra resources.
Further, the inclusion of four round one trials, and two round two trials, in Aboriginal and Torres Strait Islander communities reflects an ongoing political and public health imperative to find ways to improve access to services, improve infrastructure, and enhance individual and community empowerment in relation to health for these communities. In contrast to the rest of the Australian community, people living in Aboriginal or Torres Strait Islander communities have life expectancy, infant mortality and other key health indicators that are similar to very poor developing countries.
Council of Australian Government (COAG) Task Force on Health and Community Services, 1995: Health and Community Services: Meeting People's Needs Better
|Implemented in this survey?|
In 1994 the Council of Australian Government proposed that the organisation of health and community services could be re-structured to cater for three broad patient types: one of these types was
patients requiring a mix of healthcare services over an extended period. It was assumed that these patients would benefit by having their care proactively managed and coordinated as part of the
health service. The initial idea of coordinated care, in Australia, also had a strongly hospital cost-saving (or at least cost-neutral) intention. The idea of coordinated care can also be
regarded as an extension of the cost-containing strategies common in the USA (e.g. HMOs), and then the UK (e.g. GP fundholders), that have been broadly characterised as 'managed care'.
The first round trials did not demonstrate improved health or well-being of participants, and only three (of the nine general trials) showed significant reductions in hospital admissions. For more information, see the Department of Health and Aged Care's 1999 publication, The Australian Coordinated Care Trials: Background and Trial Descriptions and the final report of the National Evaluation.
Using lessons from the first round trials, five second-round trials are currently under way, with a longer three-year time-span (2002 until 2005). Four of these are continuations of a first round trial, and two are aimed at the health and participation in health care of Aboriginal communities.
Local level - Thirteen first round trials (1997-2000); five second round trials (2002-2005)
The coordinated care trials followed two key policy papers from the Council of Australian Government (COAG): in 1994, Health and Community Services: an Approach to Reform (unpublished);
followed in 1995, from the COAG Task Force on Health and Community Services, Health and Community Services: Meeting People's Needs Better, Commonwealth Department of Human Services and
Consumers' views about coordinated care were sought early in the process of developing the first round trials. The Consumers Health Forum's July 1996 report concluded that "consumers broadly supported the notion of the development of a coordinated care stream of health service provision", and further that trialling of these developments would be sensible. Ultimately however, whereas the consumer consultations emphasised the need for coordinated care to involve participation, partnership and empowerment of consumers, the final aims of the program were more narrowly on meeting "clients' assessed needs" (Source: Consumer Participation in Australian Primary Care: A Literature Review, March 2002, National Resource Centre for Consumer Participation in Health, La Trobe University, Melbourne - available at: www.participateinhealth.org.au/Clearinghouse/Docs/nrcpchlitreview.pdf). Nevertheless, all of the first round trials made some attempt to set up consumer participation processes and these efforts have been externally reviewed by the Consumers' Health Forum (Consumer Involvement in the Coordinated care Trials: Consultation Report, March 2000).
Stakeholder acceptance of the fundholding elements in some of the trials was more mixed, relating to concerns about: losing control over resource use; the arrangements in place to share efficiency savings with providers of the pooled funds; and, the workforce implications of a changed service mix (see Beilby J & Pekarsky B, Med J of Aus 2002, Vol. 176, pp.321-325).
We do not know to what extent community or institutional stakeholders have been consulted prior to or during the second round trials
Some aspects of the coordinated care trials - particularly in relation to 'funds pooling' - may have required regulatory changes: for example, to allow funds intended for Medicare Benefits Schedule (MBS) rebates* to be disbursed as lump sums to local fund-holders. Also, for the second round of coordinated care trials, the 1999-2000 Federal Budget allocated $33.2 million via the Enhanced Primary Care MBS items (many of which relate to reimbursing general practices for care coordination activities such as multi-disciplinary case conferences and care planning). [*The MBS is the national fee-for-service scheme under which out-of-hospital costs of medical care get subsidised by the government.]
The fact that a selection of the first round trials have been funded to continue demonstrates the government's belief that - despite their disappointing results - the principles and methods of the service changes are seen as useful. In short, the first round trials were thought to have suffered from a number of design and implementation failures; patient recruitment problems, short-term operation, insufficient tailoring to patients' different needs, poor targeting to those people most able to benefit (Esterman & Ben-Tovim, 2002). However, there is obviously a great deal of faith amongst health policy makers that coordinated care can be made and shown to 'work'.
The first round trials were very thoroughly evaluated, and the full reports of these evaluations have been published and are available on the web
(http://www.health.gov.au/hsdd/primcare/acoorcar/pubs/index.htm), including a series of papers reflecting on the evaluations, their disappointing findings and methodological problems. It is
reasonable to say that, at least within health care, these are probably the most well-documented policy experiments that have ever occurred in Australia.
The second round of five trials is also being evaluated using both local trial evaluation protocols and an over-arching national evaluation plan. Compared with the first round trials - when generic health status measures such as the SF-36 proved insensitive to many of the changes in care delivery and coordination - the second round trial evaluations will use outcome measures that are more specific to the patient groups being targeted and the expected effects of the service changes, plus questionnaires completed by carers at baseline and at intervals. Again, the 'Aboriginal trials' have broader aims and use correspondingly broad outcome measures, such as: access to primary care; involvement in population health programs; numbers of preventable hospital admissions; improved processes of care; social concerns, and; preventable mortality.
No results/findings yet from the second round trials
The current, second, round of trials is expected to:
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|
Still too early to tell. The changes in the planning and organisation of care, and the new funding mechanisms to achieve these changes, represent a highly complex package of changes that is
different in each of the localities where it is being tested.
The goal of achieving improvements in health via better care coordination may be achieved, but the first round trials indicate this might be at greater overall cost to the governement.
The Australian Coordinated Care Trials Background and Trial Descriptions, Commonwealth Department of Health and Aged Care,1999.
Esterman AJ & Ben-Tovim DI. The Australian coordinated care trials: success or failure? Medical Journal of Australia 2002; 177: 469-470.
Beilby JJ & Pekarsky B. Fundholding: learning from the past and looking to the future Medical Journal of Australia 2002; 176: 321-325.
Most reports relating to the first round of trials can be found at:
More limited (and out-of-date, Nov 2000) information about the second round trials is only available at: