Integrated Chronic Disease Management

Coffs Harbour Community Health

Kempsey Community Health

Referral criteria

• Documented diagnosis of cardiovascular disease, COPD, diabetes or congestive heart failure.
• Likely compliance to a developed care plan.
• Reside in area of coverage.
• Age >18yrs or Aboriginal and Torres Strait Islander Age >16 AND
• Have one UNPLANNED admission in the past 12 months with one of the
  chronic DRG’s OR
• Three or more unplanned admissions in a 12 month period with one of the chronic diseases as either the principle or additional diagnosis.

  Exclusion criteria apply for this service.

Port Macquarie Community Health

Referral criteria

• Documented diagnosis of cardiovascular disease, COPD, diabetes or congestive heart failure.
• Likely compliance to a developed care plan.
• Reside in area of coverage.
• Age >18yrs or Aboriginal and Torres Strait Islander Age >16 AND
• Have one UNPLANNED admission in the past 12 months with one of the
  chronic DRG’s OR
• Three or more unplanned admissions in a 12 month period with one of the chronic diseases as either the principle or additional diagnosis.

  Exclusion criteria apply for this service.

Wauchope Community Health

Referral criteria

• Documented diagnosis of cardiovascular disease, COPD, diabetes or congestive heart failure.
• Likely compliance to a developed care plan.
• Reside in area of coverage.
• Age >18yrs or Aboriginal and Torres Strait Islander Age >16 AND
• Have one UNPLANNED admission in the past 12 months with one of the
  chronic DRG’s OR
• Three or more unplanned admissions in a 12 month period with one of the chronic diseases as either the principle or additional diagnosis.

  Exclusion criteria apply for this service.