Chronic Care Program
Services offered
- Assessment and education (group or 1:1) and carer.
- Self-management strategies.
- Liaison with GP or relevant specialist.
- Education for oxygen administration.
- Post acute monitoring by HITH staff (as per clinical medical governance HITH)
- Ongoing monitoring may be referred to other community health services (including ACTIP and Generalist Community Nursing).
- Must have confirmation of diagnosis of heart failure or COPD and be suitable for home-based rehabilitation. Where the patient has a primary diagnosis of cancer, refer to cancer care coordinators in the first instance.
- If patient has limitations to self management due to cognitive impairment a mini mental must be undertaken prior to referral. If mini mental supports limited cognition, the patient must have a carer for referral.
- Must be able to be educated (or carer) in relation to self management.
- Patient is on medications that reflect their diagnosis.
- Patient/carer has agreed to referral to chronic care service and is advised that their acceptance to the program is pending chronic care staff assessment.
Referral procedures (Monday to Friday: 8.00am to 4.30pm)
Referrals can be accepted from any person or agency provided consent has been obtained from the parent/care giver/guardian of a client. Consent can be verbal or written. Parental consent required for children 0-18 years. GP referral letter is not required.
After hours referrals
Designated staff within emergency departments are to follow as per in hours referral process.