Skip to main content
Have a personal or library account? Click to login
Care Coordination for Vulnerable Families in the Sydney Local Health District: What Works for Whom, under What Circumstances, and Why? Cover

Care Coordination for Vulnerable Families in the Sydney Local Health District: What Works for Whom, under What Circumstances, and Why?

International Journal of Integrated Care
Volume 20 (2020): Issue 4
By: John G. Eastwood,  Suzannah Dewhurst,  Sally Hansen,  Elaine Tennant,  Erin Miller,  Maja Lindegaard Moensted,  Penelope Fotheringham and  Denise De Souza  
Open Access
|Dec 2020
Figures & tables

Figures & Tables

Table 1

HHAN Logic Model (created 2015).

Figure 1

Key elements of the adapted development and evaluation process.

Table 2

CMO configuration for whole of family care.

Characteristic Of ProgrammeContextMechanismOutcome
Whole of family approachClient characteristics:

  • – Distrust in healthcare services

  • – Intergenerational trauma*

  • – Financial stress*

  • – Housing and security issues*

  • – Mental and physical health conditions*

  • – Negative social and family experiences*

Acknowledging all extended family dynamics and needsAwareness of all extended family dynamics and needs
Rapport building with all family members
Client supported in the community:

  • – Client independence

  • – Client outlook improved

Acknowledgment and acceptance of HHAN by clients, families and community

[i] * Encompassed in the single term ‘vulnerability’ from this point forward.

Table 3

CMO configurations for accessibility.

Characteristic of ProgrammeContextMechanismOutcome
AccessibilityClient characteristics:

  • – Vulnerability

  • – Distrust of health services

Programme characteristics:

  • – Home visiting

  • – Place-based initiatives

Health system characteristics:

  • – Inflexibility

Approachable through multiple modes of communicationAvailable Service engagement
Accompaniment/intensive hand holdingClient characteristics:

  • – Vulnerability

  • – Disconnected from health services

  • – Fluctuating intensity of client need

Programme characteristics:

  • – Programme flexibility

  • – Providers taking dual roles

Reliability and PersistencyResponding to changes in client needs
Motivation of clients belief in own capability (positive perception)
Client independence
or
Client reliant on providers
Risk of case management model
Clinician autonomyClient characteristics:

  • – Vulnerability

  • – Diversity of age and social, cultural and health background

Programme characteristics:

  • – Flexibility

Confident cliniciansClinician holds responsibility for personal case load
Clinician and client shared decision making
Positive outcomes:

  • – Client independence

  • – Service engagement

Negative outcomes:

  • – Staff burnout

  • – Service delivery dependent on experience of staff

Navigation of health systemHealth system characteristics:

  • – Confusing

Client characteristics:

  • – Poor health literacy

  • – Distrust of health services

Confident cliniciansClinician knowledge of health system and of local services
Client navigating the health system
Wrap around care with appropriate referrals
Improved client outcomes
Planning for the future
Table 4

CMO configuration for Service Collaboration.

Characteristic Of ProgrammeContextMechanismOutcome
Service collaborationHealth system characteristics:

  • – Siloed health system

  • – Resistant to cross-service collaboration

  • – Lack of clarity about sharing of client information

Systemic barriers:

  • – Socio-economic determinants of health

  • – historical perceptions of health services

  • – Poor health literacy

  • – Geographical isolation from services

Programme characteristics:

  • – Complexity of HHAN programme making it difficult to explain to other services

Client characteristics:

  • – Vulnerability

Shared provider decision-makingRecognition of established referral pathways
Recognition of benefits of integrated care
Motivation to collaborate
Identification of collaboration opportunities
Informal and formal communication
Breakdown of silos
Collaboration between services
Recognition by service partners
Utilising appropriate services
Acknowledgement and acceptance of HHAN
Foundations for integration
Figure 2

Overarching mechanisms present at all levels of the HHAN logic model.

DOI: https://doi.org/10.5334/ijic.5437 | Journal eISSN: 1568-4156
Journal RSS Feed
Language: English
Submitted on: Oct 12, 2019
Accepted on: Oct 28, 2020
Published on: Dec 2, 2020
Published by: Ubiquity Press
In partnership with: Paradigm Publishing Services
Publication frequency: 4 issues per year
Keywords:
integrated care,
critical realism,
care coordination,
disadvantaged families,
evaluation

© 2020 John G. Eastwood, Suzannah Dewhurst, Sally Hansen, Elaine Tennant, Erin Miller, Maja Lindegaard Moensted, Penelope Fotheringham, Denise De Souza, published by Ubiquity Press
This work is licensed under the Creative Commons Attribution 4.0 License.

Volume 20 (2020): Issue 4
Previous article
Next article