Criteria for referral

• 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
• 3 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.

Services Offered

• This program aims to improve the quality of life of people and their Carers with chronic & 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.

Referral Procedure

People can self refer, internal & external agents can fax a referral to Intake Services. (See your local Community Health Centre for Community and Allied Health Referral form.)