Case Study: Embedding Care Coordinators in your team

AFHTO, in partnership with the Osborne Group, has prepared a case study for AFHTO members which looks at how five Family Health Teams (Mount Forest FHT, Sunnybrook Academic FHT, City of Lakes FHT, Guelph FHT*, and South East Toronto FHT) have effectively embedded the Care Coordinator role within primary care. Their advice to other primary care teams, and the lessons they have learned in the process, include the following:

  • Having a care coordinator as part of the team has a significant impact on quality and effectiveness of care.
  • Pay attention to the principles of change management as new models of service delivery are rolled out. Change may be difficult, and it may take some time to build relationships and trust.
  • With increased system coordination and collaboration there is a learning curve; it may take time but effective relationships are important to success.
  • Learn from other FHTs and primary care teams about their approaches so that you can build on their experience to build a collaborative model that fits the profile of your team and leverages your strengths.
  • Define the role broadly giving the Care Coordinator access to a broad array of providers and services.
  • Have a home base for the Care Coordinator at your site, or dedicated on-site time when inter-professional providers can see and talk to them. This improves efficiency and builds a sense of collaboration and teamwork.
  • Enable access to your EMR for the Care Coordinator.
  • A quality improvement perspective will contribute to a broad understanding of the role.

*Please note: The case study on Guelph FHT, which was completed in 2016, no longer reflects the current state of care coordination in the Waterloo Wellington LHIN region. The LHIN has opted for a different approach and is not embedding care coordination in primary care.

AFHTO asserts the role of primary care providers to lead care coordination. Primary care providers work to ensure access to interprofessional care for patients and identify a single point of contact to help patients and families navigate and access programs and services. The Ministry’s Patients First proposal speaks to deploying care coordinators in primary care. A number of teams have already done this and their experience can help other primary care teams as well.

Learning from your peers: additional case studies

AFHO has developed a series of case studies for our members to share the experience of colleagues on topics identified as being important to you: