Care Coordination
What Is Care Coordination?
Care Coordination focuses on ensuring that individuals receive the right support from the right services at the right time. When multiple providers are involved, care can become fragmented or confusing. This service helps bring everything together in a clear and organised way.
At TPM, Care Coordination involves working closely with individuals to understand their needs, goals, and current supports. We help coordinate communication between health professionals, community services, and other providers to ensure care is consistent and aligned.
This service supports people who may be transitioning between services, returning home from hospital, or managing complex needs that require input from multiple providers. Care Coordination helps reduce duplication, delays, and gaps in support.
By providing structured coordination and clear communication, TPM helps individuals feel supported, informed, and confident that their care is connected and working together effectively.
Who Is This Service For?
Care Coordination is designed for individuals and families who are engaging with multiple services and need support to ensure care is organised, consistent, and responsive. This service helps reduce confusion, improve communication between providers, and ensure support remains aligned with individual needs and goals.
Individuals with Complex Needs
Support for people accessing multiple health, mental health, or community services who need help coordinating appointments, services, and information.
People Transitioning Between Services
Support for individuals moving between hospital, community care, or different support services who need continuity and clear communication during transitions.
Families & Carers Managing Care
Support for families and carers who are helping coordinate care for a loved one and need guidance, clarity, and shared planning.
What We Support You With
Care Coordination focuses on helping individuals manage and navigate multiple services, providers, and supports in a way that feels organised, consistent, and manageable. When care involves different health professionals, hospitals, community services, or support providers, it can quickly become overwhelming and difficult to keep track of.
At TPM, we work alongside individuals to ensure their care is coordinated, communication is clear, and services are aligned with their needs and goals. We help reduce confusion, duplication, and gaps in care by supporting collaboration between providers and keeping the individual at the centre of decision-making.
Our approach ensures that information is shared appropriately, appointments are coordinated, and transitions between services are supported. This is especially important during periods of change, such as hospital discharge, changes in health needs, or when new services are introduced.
Care Coordination also helps individuals feel more confident and supported when engaging with multiple systems. By having a clear point of contact and structured support, people are less likely to feel lost or overwhelmed.
Care Planning
Support to develop and coordinate care plans that align with individual needs, goals, and preferences across multiple services.
Service Coordination
Assistance coordinating between health professionals, hospitals, community services, and support providers to ensure clear communication and continuity of care.
Hospital-to-Home Support
Support during transitions from hospital to home or community settings, helping ensure follow-up care and services are in place.
Ongoing Review & Follow-Up
Regular review and follow-up to ensure care remains appropriate, responsive, and aligned with changing needs.
How Our Support Works
Care Coordination at TPM is designed to ensure individuals receive consistent, organised, and connected support across multiple services. We understand that managing care often involves different providers, appointments, and systems, which can feel overwhelming without clear coordination.
Understanding Needs and Current Supports
We begin by reviewing current services, supports, and needs to gain a clear understanding of what is in place and where coordination is required.
Coordinating Services and Communication
We liaise with service providers, health professionals, and support networks to align care, improve communication, and reduce duplication or gaps.
Ongoing Review and Adjustment
We continue to monitor and adjust care coordination as needs change, ensuring supports remain relevant, effective, and well-connected.
Who We Work With
Care Coordination at TPM is delivered through collaboration with a wide range of professionals, services, and support networks. Effective coordination relies on strong communication, shared understanding, and respect for each provider’s role in supporting the individual.
We work closely with individuals to ensure their preferences, goals, and concerns are understood and reflected in coordinated care. Individuals remain actively involved in decisions and are supported to understand how services work together.
Families and carers are also key partners in care coordination. With consent, we involve them to support understanding, continuity, and shared decision-making.
In addition, we collaborate with health and community service providers to ensure care is aligned, information is shared appropriately, and transitions between services are well managed.
Individuals
Support for individuals who require coordination across multiple services to ensure care is consistent and aligned.
Families and Carers
Collaboration with families and carers to support understanding, communication, and continuity of care.
Health & Community Providers
Coordination with GPs, hospitals, allied health, and community services to align care and reduce service gaps.
What Our Clients Say
Frequently Asked Questions
Care Coordination often supports people who are working with multiple services, providers, or systems at the same time. It is common to feel overwhelmed, confused, or unsure about who is responsible for what, especially during transitions such as hospital discharge or changes in care needs.
What is Care Coordination?
Care Coordination supports individuals by organising and coordinating services across health, mental health, aged care, and community systems to ensure care is consistent, connected, and well-communicated.
Who is Care Coordination suitable for?
This service is suitable for individuals who are working with multiple providers, transitioning between services, or needing support to manage complex or ongoing care needs.
Do you work with hospitals and GPs?
Yes. We work with hospitals, GPs, specialists, community services, and other providers to support coordinated care and clear communication.
Is Care Coordination a clinical service?
No. TPM provides non-clinical care coordination. We do not provide medical treatment but support communication, planning, and connection between services.
Can families or carers be involved?
Yes. With consent, families and carers can be involved to support shared understanding, communication, and coordinated care planning.
Do I need NDIS or aged care funding?
No. Care Coordination is available to individuals with or without NDIS or aged care funding. We can also help explore suitable support pathways.