The Issue
SA HealthPlus was the largest of nine trials led by the Australian government to test whether coordinated care could improve health outcomes for patients with chronic conditions, without incurring added costs. The care coordination model relies on prospective planning to help patients manage care and avoid complications.
What the Study Found
Previous studies indicated that the SA HealthPlus trial resulted in some improvements in patients' health and reduced hospital admissions, but not to the extent that the intervention paid for the additional costs of the coordinated care. This Commonwealth Fund–supported study highlights the innovative aspects of this model of care coordination, including:
- outcomes-based payment, whereby the funds for all aspects of care for a defined patient population are used to achieve particular health outcomes;
- a 12-month patient care plan shared among providers that measures outcomes over time, facilitates communication, and serves as a motivational tool;
- a focus on patients' self-identified problems and goals; and
- use of service coordinators to enroll patients, conduct assessments, draft care plans, and arrange community services.
Conclusions
The trial demonstrated that focusing on patient psychology—by targeting patients' perceptions of their disease and helping them change their behavior—is a key part of coordinating care. It also found that the health benefits of coordinated care depended more on patients' ability to manage their condition rather than the severity of their illness.
