
Coordinated care in Primary Care Centres – what does it mean?
From 1 October 2022, Primary Care Centres have the option to provide coordinated patient care. At present, this service is not available in all Primary Care Centres, but its availability will increase.
Patients under coordinated care have the opportunity for faster diagnosis and treatment of selected chronic diseases with their primary care doctor (POZ), without the need for an appointment with a specialist doctor within the framework of treatment in AOS. The POZ clinic should provide selected specialist consultations for its patients (cardiologist, diabetologist, endocrinologist, pulmonologist/allergist), and the POZ doctor refers.
As part of coordinated care, chronically ill patients are also covered by health education, through which they will be able to learn how to cope with their illness. If necessary, the family doctor can refer the patient to a dietitian (e.g., after a diabetes diagnosis).
As part of coordinated care, a primary care physician can order tests (if there are medical indications) for which previously only a specialist doctor working in a hospital or specialised clinic could issue a referral (e.g., stress ECG, Doppler ultrasound of lower limb vessels, echocardiogram, or thyroid test panel: anti-TPO, anti-TSHR, anti-TG). The doctor will order the appropriate tests for you, depending on what you are suffering from.
What diseases can you treat under coordinated care in Primary Health Care?
The GP will be able to provide comprehensive care for patients with selected conditions in the following areas:
• cardiology;
Diabetology;
• lung diseases;
• endocrinology;
• Nephrology.
At your appointment – ask your doctor if you can be enrolled in coordinated care (List of diseases).
Comprehensive advice within coordinated care refers to a holistic approach to patient management that considers all aspects of their health and well-being, not just the immediate medical issue. It involves a multidisciplinary team working together to create a personalised care plan tailored to the individual's needs.
This type of advice can be beneficial for a wide range of individuals, including:
* **Patients with chronic conditions:** Such as diabetes, heart disease, or respiratory illnesses, who require ongoing management and support.
* **Elderly patients:** Who may have multiple health concerns and require assistance with daily living activities.
* **Patients with complex needs:** Including those with mental health conditions, disabilities, or who are recovering from surgery or serious illness.
* **Carers:** Who may need guidance and support in managing the care of a loved one.
* **Individuals seeking preventative care:** Those who want to improve their overall health and reduce the risk of future health problems.
If a doctor diagnoses you with one of the illnesses within cardiology, diabetology, pulmonary diseases, or endocrinology, they will conduct a comprehensive consultation which includes: a medical history, a physical examination, analysis of test results and current treatment, recommendation of necessary specialist consultations and diagnostic tests, as well as the development of an Individual Medical Care Plan.
Individual Care Plan (ICP) – what is it?
The IPOM is your treatment plan, developed by your GP. This plan includes diagnostics, treatment, follow-up appointments, and dietary advice. Your doctor and a designated coordinator will oversee the implementation of this plan.
REMEMBER: ultimately you are responsible for your health and the implementation of this plan.
What should an Individual Care Plan include?
The IPOM should include recommendations for: follow-up visits, educational advice given by nurses or doctors, follow-up examinations, and dietary consultations.
What are the tasks of a coordinator in coordinated care?
The coordinator in the Primary Care Centre is a guide and caregiver for the patient. The coordinator supports the doctor in communicating with the patient, contacts the patient to discuss further treatment stages, reminds them about tests and follow-up appointments, or recommended preventative measures, and also ensures cooperation between the people involved in the patient's care.
Websites about coordinated care: