Focusing on burden and capacity to support self-management of chronic health conditions: A pilot trial of care coordination in rural Australia

Introduction: Managing multiple health conditions can create a demanding workload, especially when capacity is limited. This can lead to disengagement and poor health outcomes. Our pilot trial explored the feasibility of care coordination using a minimally-disruptive medicine approach. Methods: The setting was a community health service in rural Victoria, Australia. People with multimorbidity and complex life demands were linked to care coordinators who evaluated and addressed burden and capacity imbalance, informed by client priorities. Clinicians underwent training in capacity-burden assessment and participated in ongoing case conferencing. A mixed-methods evaluation was undertaken guided by Bowen's feasibility framework with treatment burden and quality of life as quantitative outcomes. Results: 26 clients (mean age 66.5 years) engaged with 3 care coordinators. Clients reported high treatment burden with a mean of 11 chronic conditions each, dominated by mental health and chronic pain conditions. The program was highly acceptable to clients, who reported increased control over their health and life demands. Six-month outcomes showed a significant reduction in treatment burden level (MMTBQ) p=0.019, Phi=0.524 and improvement in quality-of-life scores (EQ-VAS) p=0.019. Clinicians valued the program and highlighted the importance of putting aside one's discipline lens and focusing on the client priorities, aided by the assessment tools and training. Discussion: A burden-capacity model of care coordination is feasible in the community health setting and may lead to reduced treatment burden. Barriers identified were related to community health funding and structures favouring single diseases and disciplinary boundaries, which may not reflect the lived experience of clients.