Connecting Care in the Community Program

Services offered

  • This program aims to improve the quality of life of people and their carers with chronic and complex conditions such as COPD, coronary heart disease, chronic heart failure, diabetes and hypertension.
  • Comprehensive assessment of care needs.
  • Multidisciplinary care plan coordinated with the client, their carer, GP and other health and community care providers.
  • Education and self-management of the chronic illness.
  • Initiation and coordination of services as required.
  • Documented diagnosis of cardiac disease, COPD, hypertension, 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.

Self or family/carer can refer to this service.


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