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.


119 River St
West Kempsey NSW 2440

Morton Street
Port Macquarie NSW 2444

69 High Street
Wauchope NSW 2446

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