Chronic disease coordinated care planning: flexible, task-centered decision support

SA HealthPlus is a trial of coordinated care enrolling 4000 high-use patients in South Australia in 10 groups including diabetes, cardiac, aged care and lung disease. These patients each have a designated general practitioner (GP) care coordinator who formulates an individualized care plan designed to keep them as healthy as possible. An on-line interface to SA HealthPlus has been developed for the care coordinators. The Care Plan On-Line (CPOL) system provides a single coherent source whereby the GP can review the available information on a HealthPlus patient in the context of devising a care plan of prospective services and medications. In the same application environment CPOL provides access to care guidelines tailored for SA HealthPlus.