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 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.

Contact

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