Collaborative care and support planning



GPs are crucial for providing continuity and care coordination; we know that people living with chronic conditions will do better if a GP is at the centre of their care, maintaining regular contact with them. General Practitioners can make a big contribution toward providing better coordinated care that is centred on your patients’ health and wellbeing needs.

But we know that interventions and care planning approaches that focus on single conditions can lead to chaotic overall care for patients…

Like most GPs, you’re already at capacity; who can take on the extra work involved in care coordination and/or case management of your patients with multiple and/or complex, chronic conditions?

No one can ask you to care more or work harder than you already do. But can we work smarter, together?


Care Assess is a specialist in health assessment and collaborative care and support planning, able to provide your patients with a pro-active approach to care involving assessment of needs and care planning, to better support you and your surgery/fellow GPs.

Care Assess has a demonstrated effective approach in undertaking care coordination for complex care patients by engaging patients and all relevant providers in collaborative care planning and the management of a single holistic care plan.

We can work with you and your practice to switch from a disease focus to a patient-centered care planning system.

We can work with your organisation, within the culture of your practice, with your recall systems and your whole team. We’ve helped many GPs and surgeries, and we have experienced health professionals and practice managers ready and willing to help.

Care planning was created by clinicians who were exhausted and dissatisfied with the status quo – good doctors lacking the time, space and back up to be really great doctors.

Care Assess has in place improved community-based services for people with chronic health conditions that enable them to live well and avoid unnecessary complications or crises.

Collaborative care and support planning isn’t impossible and it’s worth the effort!

A GP’s story

It’s 5:30 in the afternoon and you have several patients left to see, when in comes Rose. She lives with osteoarthritis, diabetes and COPD. Her notes are long and are filled with missed appointments and overdue tests. Rose’s daughter made the appointment because her breathing has been a ‘bit up and down’. Her mood seems low, but with only ten minutes there is little time to find out why; just enough to repeat her prescription, take her blood pressure and suggest more appointments. She probably won’t make these or many other consultations like this one as her conditions gradually worsen. Your heart sinks…

But it doesn’t have to be like this!

Rose’s life is complex. She’s cared for by her daughter, but she also cares for her grandson with behavioral difficulties. Despite her multiple conditions, she is confused by medical jargon. She knows that your prescriptions work in the short term, but with a lot going on, spirometry and blood tests seem theoretical and less important than supporting her daughter and dealing with her grandson’s tantrums. There’s no medical fix for this.

Rose needs support specific to her and her situation. She needs a network around her! But since you are already at capacity, who can take on this extra work?

No one can ask you to care more or work harder than you do already.

But together with Care Assess, as a team, can you work smarter?

Imagine if before seeing you, Rose had already had a health assessment in her own home by a registered nurse, able to plan her care as part of the team in your practice, and coordinate her services. Designed to draw the support from other organisations and the wider community, they work with Rose and the people closest to her, people like her daughter; a health professional, who have gone through the stages of care planning already: And so all of this has already taken place.

This would be a very different type of consultation, with time to listen, understand what matters to Rose and continue to develop her ongoing care plan together.

Now you have the time to see your work really making a difference.

Track record

  • Since 1999 Care Assess has collaborated with General Practice through the provision of health professionals such as nursing and allied health care services to provide home assessment and care coordination under the supervision of the client’s GP.
  • Care Assess undertake Comprehensive Health Assessments and Care Planning (including Comprehensive Medical Assessments in Residential Aged Care) on behalf of General Practitioners.
  • Care Assess has demonstrated a long established ability to provide nursing and clinical assessment services, work with general practice and interface between community, primary care and residential care.