Chronic illness is a significant contributor to the global burden of disease, with markedly increasing prevalence and associated stress on health care systems . In Australia, 80% of the estimated total burden of disease is attributed to chronic illness, primarily cardiovascular disease, chronic respiratory conditions, diabetes and cancer .
Population ageing exacerbates the burden of chronic disease in developed countries . Health service needs for older populations are complex, involving multiple comorbidities and a broader range of service providers . It is estimated that among independently living Australians, almost half aged 65–74 have five or more chronic conditions, increasing to 70% of those aged 85 and over .
People with multiple chronic illnesses are major consumers of health care services , accounting for 70% of general practice consultations. They are twice as likely to be admitted to hospital, and stay in hospital disproportionately longer . The substantial cost to government is further challenged by the need to strengthen disease prevention initiatives while providing care to a growing number of patients with chronic disease .
High health care costs are driven by the episodic nature of standard health services, which are focused around acute care. This model may be poorly structured and unsupported in the context of patients with chronic illness who can require multiple presentations across private medical specialists, community health, general practice, allied health, and hospital inpatient and outpatient clinics. International research over the past decade suggests that chronic illness may be more effectively treated by better connecting patients’ health management from hospital to community-based services [2, 3, 5, 7–12]. Coordinated care has been identified as a solution which provides this link.
The aim of coordinated (or integrated) care is to enhance quality of care and quality of life, consumer satisfaction and system efficiency for patients with complex, long-term problems across multiple services, providers and settings . Coordinated care can take on a variety of forms, but always involves multidisciplinary communication and care planning [9, 14]. Trials to assess the effectiveness of coordinated care have been conducted across the OECD, including in Australia, USA, Canada, England, Italy, Denmark and France [2, 3, 5, 7–12].
A positive effect of community-based care has generally been shown in trials, with lower rates of hospitalisation and lower costs [3, 8, 10]. Improvements in the level of service access and patient knowledge have also been observed . However, there is inadequate evaluation of the outcomes, and particularly the implementation, of coordinated care interventions within health services. Within the Australian setting, a randomised controlled trial (RCT) of the outcomes of face-to-face coordinated care has not been conducted . More broadly, trials are often focused on specific conditions or population subgroups, and are conducted with small sample sizes and over short timeframes. In addition, trials conducted to date employ a highly variable degree of service coordination.
Solid evidence is required of the effectiveness of care coordination to improve patient outcomes in the population. Implementation of care programs must be evaluated in a way that allows health services to gauge which of its components (e.g., emergency department, wards, discharge, community practitioners) and which of its stakeholders (e.g., patients, carers, nurses, doctors, management, policymakers) facilitate or create barriers to the effectiveness of the new interventions.
A randomised control trial (RCT) will be conducted to measure the impact of an in-hospital coordinated care intervention, Care Navigation (CN), on health service use and quality of life in elderly and chronically ill patients in Western Sydney, Australia. Effectiveness is based on emergency hospital presentations, hospital admissions and quality of life over 24 months. An economic evaluation examines the cost-effectiveness of CN against current standard care from the perspective of the health sector. A process evaluation will also be conducted to describe the organisational setting and context within which CN has been developed and implemented.