Chronic Care Coordinator

Criteria for referral

  • Documented diagnosis of Cardiac Disease or COPD
  • Likely compliance to a developed care plan
  • Reside in the Coffs Harbour LGA
  • Unplanned readmission within 28 days x 1 or more within a 12 month period
  • ED presentations ≥ 5 times within a 12 month period
  • 3 or more admissions in a 12 month period related to Cardiac disease or COP DRG.

Services Offered

  • Comprehensive assessment of care needs
  • Multi-disciplinary 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.

Service exclusions apply for this service.

Referral Procedure

  • Self (or family/carer) referral to Intake
  • Internal & external agents fax referral to Intake – phone to check received
  • Community & Allied Health Services Referral Form (access the Community and Allied Health Referral form your local Community Health Centre on this website).

 

 

Services available at these locations

Coffs Harbour LGA

Coffs Harbour Community Health
345 Pacific Highway
Coffs Harbour NSW 2450

via Intake Officer

Phone 02 6656 7646

Fax 02 6656 7610