CareNet Operating Model

1. Why an Operating Model Is Needed

A connected care system requires more than a collection of services and providers. It needs a clear way to bring the right participants together, establish responsibilities, and coordinate activities.

A family may need daily assistance at home, a medical appointment, rehabilitation, and communication with relatives who live elsewhere. Different people or organisations may be responsible for these activities.

Without an agreed operating approach, families can be left to coordinate every detail themselves. Providers may also lack clarity about who should communicate an observation, arrange follow-up, or respond when circumstances change.

The CareNet Operating Model is intended to provide a shared framework for addressing these challenges.

Its purpose is to help answer five practical questions:

• What support does the person need?
• Who is responsible for each agreed activity?
• How will the relevant people and services be connected?
• What information should be communicated, to whom, and when?
• How will follow-up and changes in requirements be handled?

The model does not imply that every arrangement will involve a dedicated coordinator or that every activity can be managed centrally. Responsibilities depend on the service arrangement and the participants involved.

2. The Participants and Their Responsibilities

CareNet brings together participants with different roles. Clear boundaries help them work together without assuming responsibilities that belong to someone else.

The Person Receiving Care

The person receiving care is central to the arrangement.

Their needs, preferences, dignity, circumstances, and ability to participate should guide care planning. Consent, decision-making authority, and the involvement of representatives must be handled appropriately.

Family Members and Designated Contacts

Family members often explain the initial requirement, share relevant context, participate in agreed decisions, and help coordinate support.

A designated family contact may receive updates or help communicate decisions to other relatives. Access to personal or healthcare information must be appropriate to the person’s consent, authority, and applicable requirements.

Being a family member does not automatically authorise unrestricted access to another person’s information.

Care Providers and Workers

Care providers deliver the activities within their agreed scope.

Their responsibilities may include carrying out assigned activities, communicating relevant observations, following applicable safety procedures, maintaining appropriate records, and raising concerns through the agreed channels.

The tasks assigned must match the provider’s capabilities, qualifications, and authorisations.

Care Coordinators or Responsible Contacts

Where the arrangement includes a coordinator or designated responsible contact, that person helps connect the relevant participants and activities.

Depending on the agreed scope, responsibilities may include clarifying requirements, communicating arrangements, following up on outstanding matters, and helping the family understand the next steps.

Coordination does not confer clinical authority or automatically make the coordinator responsible for every action performed by an external provider.

Healthcare Professionals and Facilities

Doctors, specialists, hospitals, clinics, diagnostic providers, and other healthcare professionals remain responsible for the clinical services they provide.

They determine clinical assessments, diagnoses, treatment, and medical decisions within their professional scope. CareNet may help coordinate access, appointments, referrals, practical arrangements, and follow-up where those activities are agreed and available.

External Service and Community Partners

Partners contribute specific services, facilities, expertise, or local capabilities under agreed arrangements.

Their responsibilities, availability, qualifications, and service scope should be established rather than assumed. Each organisation remains responsible for its own agreed activities and applicable obligations.

WARA

WARA’s role is to help families navigate appropriate support and, where agreed and available, connect relevant services and participants.

The exact responsibilities undertaken by WARA depend on the service being arranged, the location, the participating providers, and the terms agreed with the family.

WARA’s coordinating role does not replace healthcare professionals, service providers, or emergency authorities.

3. From Requirement to Coordinated Care

The operating model uses a common journey that can be adapted to different needs.

Step 1: Understand the Situation

The family or an authorised representative describes the concern, the person’s circumstances, the support already available, and the help being sought.

Relevant information should be collected proportionately and handled responsibly.

Step 2: Identify the Required Support

The requirement is considered in terms of the activities and capabilities needed.

This may involve one CareNet or a combination of ElderCareNet, HomeCareNet, HealthCareNet, and AyushCareNet.

Where clinical assessment is required, the matter must be referred to an appropriately qualified healthcare professional.

Step 3: Define the Arrangement

Before services begin, the relevant responsibilities and expectations should be clarified as appropriate to the service.

This may include:

• The activities to be performed.
• The people or organisations responsible.
• The expected schedule and scope of support.
• Communication and family-update arrangements.
• The handling of observations and concerns.
• Follow-up responsibilities.
• Relevant limitations, costs, and service terms.

The level of detail will vary according to the service and the risks involved.

Step 4: Connect the Participants

WARA may help identify and coordinate suitable people or services within the agreed arrangement.

This may involve a care provider, a healthcare service, a rehabilitation professional, a family contact, or another partner.

The arrangement depends on the availability and suitability of the relevant participants.

Step 5: Deliver the Agreed Activities

Each provider performs the activities within its agreed scope and professional responsibilities.

Relevant instructions, changes, and concerns should be communicated through appropriate channels. If the requirement changes, additional support may need to be discussed and agreed.

Step 6: Communicate and Follow Up

Where included in the arrangement, relevant activities, observations, outstanding matters, and follow-up may be recorded or communicated to authorised participants.

The aim is to reduce avoidable gaps between activities and help the family understand what has been arranged and what may require further attention.

Step 7: Review and Adapt

Care needs may change following illness, hospitalisation, changes in mobility, or changes in the family’s circumstances.

The arrangement may therefore need to be reviewed, adjusted, continued, or concluded. Any changes should be communicated to the participants whose responsibilities are affected.

These steps describe the intended operating framework. Not every service will follow an identical sequence, and not every step is performed by WARA.

4. How the Four CareNets Participate

The operating model maintains separate responsibilities while allowing relevant networks to work together.

These descriptions identify the intended roles of the networks; they do not establish that every listed activity is currently available in every location.

5. Communication and Information Flow

Care coordination depends on relevant information reaching the people who need it for an agreed purpose.

For example, a care provider may observe a change that should be communicated to the designated family contact or an appropriate healthcare professional. A healthcare provider may recommend follow-up that the family needs help arranging.

The operating model should establish, where relevant:

• Who is authorised to communicate information.
• Who should receive a particular update.
• Which matters require follow-up.
• How observations and concerns should be documented.
• How changes in responsibilities are communicated.
• How personal and healthcare information is protected.

Information should be shared only with appropriate participants and for legitimate purposes, subject to consent, authority, privacy safeguards, and applicable requirements.

The model does not imply that every participant has access to all care information or that communication and records are automatically synchronised.

For more detail, see the [Care Ledger](/care/ how-care-works/care-ledger/) and Healthcare & Care Information Privacy.

6. Handling Concerns and Unexpected Situations

An operating model must account for concerns that arise during care.

The appropriate response depends on the nature and urgency of the situation.

For a routine concern, the responsible provider or contact may need to be informed and a follow-up agreed. A change in care requirements may require a review of the arrangement. A clinical concern may require assessment by a qualified healthcare professional.

In an immediate or life-threatening emergency, the appropriate local emergency service must be contacted without delay. Families and providers must not wait for WARA or a routine coordination process before seeking emergency assistance.

The intended Emergency Response Network provides a framework for communication and coordination when suitable local arrangements are established. It is not a guarantee of automatic detection, continuous monitoring, immediate response, ambulance availability, or a particular outcome.

Read the Emergency Response Network framework.

7. The Role of Records and Accountability

The Care Ledger is intended to support appropriate records of agreed activities, relevant observations, coordination, and follow-up.

These records may help clarify what was reported, which action was agreed, and whether a follow-up remains outstanding—where the relevant recordkeeping capability is available and included in the arrangement.

Accountability also requires clarity about who performed an activity, who was responsible for a decision, and who was expected to take the next step.

Records alone do not prove that an activity was performed correctly, that a person is safe, or that a healthcare outcome was achieved. Appropriate review and professional judgement remain essential.

The information collected and retained must be proportionate to the purpose and protected through suitable access controls and procedures.

8. The Partner Operating Model

External partners are essential to a system that aims to connect different forms of care across locations.

A suitable partnership arrangement should clarify:

1. The organisation’s identity and relevant credentials or authorisations.
2. The services it can provide and the limits of its scope.
3. The locations and circumstances in which services are available.
4. The responsibilities of the partner and WARA.
5. The process for referrals, communication, and follow-up, where applicable.
6. Relevant service terms, privacy responsibilities, and escalation arrangements.
7. How the relationship and service status will be reviewed.

Verification should mean that specified checks have been completed at a particular time. It should not be represented as a permanent guarantee of quality, safety, performance, or availability.

The detailed partner framework remains dependent on the partner category and the arrangements established with each organisation.

Explore the Partner Ecosystem.

9. How Learn, Work, and DharmaNet Support the Model

The operating model is supported by the wider WARA system.

Learn can contribute to the development of relevant knowledge and practical capabilities. Training must be appropriate to the activities being undertaken and does not replace mandatory qualifications or authorisations.

Work can help organise people, responsibilities, and service opportunities around defined requirements.

DharmaNet represents shared local and community infrastructure that may help connect care with learning, work, and community support.

Partner provides the wider collaboration dimension through which external providers, institutions, and programme partners may contribute.

These are supporting dimensions, not additional CareNets. Their contribution depends on the relevant programmes, people, and arrangements being established.

10. Operating Principles

The following principles should guide how the model is implemented.

• Clarity: Every agreed activity should have an identifiable scope and responsible participant.
• Proportionality: The arrangement should match the person’s needs and the nature of the service.
• Consent and dignity: The person’s preferences, decision-making authority, and privacy must be respected.
• Professional boundaries: Clinical decisions and specialised activities remain with appropriately qualified professionals.
• Communication: Relevant information should reach authorised people through agreed channels.
• Accountability: Responsibilities, concerns, and follow-up should be clear.
• Local suitability: Services must reflect actual availability and the capabilities of participating providers.
• Honest representation: Planned processes must not be presented as operational capabilities until they are established.

11. From Operating Model to Implementation

The operating model describes how participants are intended to work together. Implementation requires more specific arrangements, including service definitions, assigned responsibilities, trained personnel, partner agreements, communication procedures, privacy safeguards, and suitable supporting systems.

These details may vary by service and location. Sensitive implementation instructions, contractual terms, detailed internal procedures, and commercial arrangements belong in controlled-access internal documentation rather than this shareable overview.

The model should be refined as WARA develops its services, gains operational experience, and establishes appropriate partnerships.

Explore the Wider CareNet System

• CareNet Vision — the purpose and guiding principles.
• CareNet Architecture — the relationship between the four CareNets and shared capabilities.
• Partner Ecosystem — external providers and collaboration.
• Roadmap — development priorities and intended direction.
• Care Process — the practical journey from requirement to review.
• Coordination Model — the supporting coordination framework.
• WARA Care — the family-facing overview of services.

The intended outcome is a care arrangement in which people understand their responsibilities, appropriate services can work together, and families have a clearer path through changing care needs.