For Patients and Visitors
What is the Service?
Care coordinators are healthcare clinicians who work with clients and their carers or family, to ensure that they receive the care and support that they want and need, to live safely in the community.
Care Coordinators aim to:
- Keep people well and out of hospital.
- Help people who may benefit from having a health professional coordinate their healthcare.
- Help people work out what is important to them and their family.
- Help people access services to help them live as independently as possible.
- Provide education to help people feel more confident in managing their health, medications and appointments
- Link people into services and supports.
What can I expect from the service?
Care coordinators will:
- make contact through telephone and visit clients in their home.
- Listen carefully to the clients’/family concerns, and work out a plan to help the client and family manage out in the community.
- Find answers to the questions that client has, and provide information that will help keep our clients safe at home.
- Coordinate care with other health professionals and GPs, to ensure they all have the information they need, to help the client to stay well at home.
Our team includes: Registered Nurses, Occupational Therapists, Social Workers, Physiotherapists, Pharmacist, Psychologist, Speech Pathologists, Medical Doctors and Geriatricians.
We also have nurses who specialise in the management of Respiratory and Heart Failure Conditions.
What do I bring/need for my appointment?
You may be contacted by telephone, home visits and telehealth (Video Calls). If a family member, carer or friend would like to be involved, it would be useful for them to be part of this journey. An accurate list of medications, the name and clinic address of your GP, and a list of any specialists and services that you already receive would be helpful.
Please let us know, if you require an interpreter or use of AUSLAN.
Enquiries and Referrals:
Community Access Helpdesk:
Our offices are staff Monday to Friday 8:30 am -4:30pm
Free Call: 9495 3443
Fax: 8405 8616
Email: Community. Community.Access.Helpdesk@nh.org.au
For Health Professionals
Service Overview
Care Coordination is offered by the Hospital Admission Risk Program (HARP). Care Coordinators work with clients who are at risk of hospital readmission due to chronic disease, frailty or complex psychosocial issues.
Care Coordinators may have a nursing or allied health background. They undertake holistic assessment which identifies the concerns of the client and family, and key factors that place the client at risk of unplanned readmission and/or ED attendance. A care plan and goals are developed with the client, which may lead to (but not limited to) referrals to other services, medication review, health-coaching and equipment provision. Care Coordinators liaise with health providers working with the patient to ensure a single, cohesive history and holistic approach, which meets the clients’ goals.
Inclusion criteria:
Unplanned hospital admission in the last 12 months
Risk of representation (where no other local service can meet the clients’ needs)
Reside in Northern Health catchment
May live in the community or Residential Aged Care Facilities
Exclusion criteria:
Patients with acute psychiatric condition – please refer to an area mental health service.
How to Refer:
To refer, please contact the Community Access
Fax: 8405-8616
Email enquieries only: Community.Access.Helpdesk@nh.org.au
Referral must include:
- Past medical history, including a current medication list
- Specialists providing care to the patient (public and private)
- Current community services/supports involved
- Functional status and social history
- Alternative contact details for the client
- Interpreter requirements
- Medical details
For Respiratory and Heart Failure streams:
- Recent medical discharge summary, including outpatient follow up appointments
- Imaging results (TTE, ECG, RFT’s)
- Biochemistry
- Target weight/fluid restrictions
General Enquiries:
For general enquires only: the HARP office is staffed Monday to Friday 8.00 am to 4.30 pm
Free Call: 9495 3294
