This review project commissioned by the NSW Ministry of Health aims to inform the development of a shared understanding of care navigation, care coordination and health coaching based on the literature and the experience of existing programs in NSW.

Project Status

Completed Projects

Chief Investigator- Mark Harris. Other investigators- Julie McDonald, Terry Findlay, Gawaine Powell Davies, Sharon Parker, Sarah Dennis, Louise Thomas, Rachael Kearns


Delivering integrated care is one of three strategic directions of the NSW Health Plan: Towards 2021. The NSW Integrated Care Strategy launched in 2014 aims to reduce the fragmentation of health services through the delivery of seamless effective and efficient health care. For people with chronic and complex conditions, who are high users of health services, this translates to a system of care that is responsive, multi-disciplinary and coordinated and one which maximises the empowerment of patients and their carers, and reduces unnecessary demands on acute health services. Prior to this, the Chronic Disease Management Program (CDMP) was established in 2010-11 as a state-wide program to improve care coordination and self-management for those people identified as being at risk of unplanned hospitalisation/ED use. It is currently undergoing a redesign process and being aligned with the Integrated Care Strategy.


The evaluation of the CDMP found considerable variation between and within local health districts in their models of care coordination and self-management, including health coaching. A lack of clear definitions or expectations about care coordination and self-management meant that Local Health Districts (LHDs) developed their own models that reflected their history and local circumstances. The current review aims to inform the development of a shared understanding of care navigation, care coordination and health coaching based on the literature and the experience of existing programs in NSW.



The objectives of the project are to:

  • review the integrated care interventions of care navigation, care coordination and health coaching (with specific emphasis on the latter),  describe their components and what each aims to achieve in relation to chronic conditions management;
  • explore the relationship/s between chronic conditions health coaching and interventions designed to improve coordination and navigation of services generally for people with chronic disease; and to explore the relationship between health coaching and support services offered to patients transitioning from acute care;
  • provide a comprehensive understanding of the care navigation, care coordination and health coaching currently being utilised in NSW LHDs and networks including the systems, processes and infrastructure supporting service delivery and how these can be recorded and reported under Activity Based Funding (ABF); and
  • based on this review, comment on the ability of LHDs to support the three integrated care interventions and make recommendations for future service delivery within the current policy context



A focused literature review was conducted to identify current definitions for health coaching, care navigation and care coordination, as well as information about components and delivery methods for these interventions. Program data on current health coaching, care coordination and care navigation activities was collected from LHDs through a structured survey. A mixed sample of LHDs participated in semi-structured telephone interviews to discuss the enablers, barriers and opportunities for the implementation of each type of intervention. The findings of the literature review and analysis of program information collected from the LHDs were used to describe how health coaching fits in relation to the other two interventions. A small group of experts were consulted to guide this understanding.


Publications and Presentations

Report in preparation


Mark Harris Phone: 02 93858384 Email:

Project lead centre
Project stream
Prevention and Management of Long Term Conditions
Project start date
August 2016
Project end date
December 2016