Chronic Care Program

Criteria for Referral to the Service

  • 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-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 NOT required.

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)

After Hours Referrals

  • Designated staff within Emergency Departments are to follow as per in hours referral, but will attend this next working day and be available to contact chronic care staff and discuss the situation
  • Service Confirmation to Patients
  • Will be within two working days of referral acceptance by chronic care staff.

Services available at these locations


Kempsey Community Health
Polwood Street
Kempsey NSW 2440

Phone 02 6561 2790
Fax 02 6562 0325

Port Macquarie

Port Macquarie Community Health
Morton Street
Port Macquarie NSW 2444

Phone 02 6589 2100
Fax 02 6589 2160


Wauchope Community Health
High Street
Wauchope NSW 2446

Phone: 02 6580 8060
Fax to 02 6580 8061

Staff work part-time – Monday, Tuesdays and Thursday