Connecting Care

Objectives of the Program:

• A reduction in the projected number of people admitted to hospital with an avoidable admission.
• Provide integrated chronic disease management across all of ESDGP Primary Care Practitioners and SESIAHS.
• Build workforce chronic disease management skills, capacity and capability.
• Build the capability of primary health, SESIAHS hospitals and community based services to deliver a chronic disease self management support service locally.
• Facilitate the change management process for clinicians in the management of patients enrolling in the program.

The Chronic Care Facilitator:

• Coordinates care for patients enrolled on the SESIAHS Connecting care program as provided by SESIAHS.
• Actively case manages patients including recommending appropriate referrals and incorporating information from existing care plans.
• Liaise with the patient’s general practitioner regarding the coordination of care
• Actively support and educate general practice staff within ESDGP geographic boundaries in the management of chronic disease and care coordination.

Collaboration:

• DOHA, NSW Health, Primary Care Practitioners, SESLHN (South Eastern Sydney Local Hospital Network) - Prince of Wales Hospital, Sydney Hospital and associated Community Services such as PACS, ACAT, Heartlink, RCCP, and Diabetes Service.
• Special Health Network - St Vincent’s Public Hospital

Eligibility:

• Patients will be identified by disease group (ICD Code – International Classification of Disease).
• Aged over 18 years or aged over 15 years if they are Aboriginal and Torres Strait Islander decent
• At least three unplanned acute hospital admissions in the last 12 months with one of the following 5 diseases as their principal diagnosis: Diabetes, Congestive Heart Failure (CHF), Coronary Artery Disease (CAD), Chronic Obstructive Pulmonary Disease (COPD) and Hypertension.

Health Coaching: The contract for telephony health coaching services has been awarded to Healthways Australia. Patient eligibility and referral pathways are under negotiation.

Relevant Links:

www.heartfoundation.org.au/heartweek or 1300 362 787
www.diabetesaustralia.com.au or 1300 136 588
www.nutritionaustralia.org
www.copdx.org.au/the-copd-guidelines
For a COPD Information Pack, through the Australian Lung Foundation.

Connecting Care Patient Information Brochure

 For further details on Connecting Care contact  Division on 93890874 ext. 206.