Care Coordination Program
North Coast Area Health Service Priority Health Care Program
CLIENT INFORMATION
WHAT IS THE CARE COORDINATION PROGRAM?
The Care Coordination Program is designed to coordinate care for people with conditions such as Heart Failure, Chronic Obstructive Pulmonary Disease (COPD) including Emphysema.
WHO IS ELIGIBLE FOR THE PROGRAM?
People of all ages who have chronic and complex needs with a diagnosis of:
¨ Heart Failure
¨ Chronic Obstructive Pulmonary Disease (COPD) including Emphysema
WHAT ARE THE AIMS OF THE PROGRAM?
· To prevent crisis situations and reduce urgent and unplanned admissions to hospital
· To improve the quality of life for people with Heart Failure, COPD and Emphysema
· To improve the quality of life of their cares and families
WHAT SERVICES ARE PROVIDED?
· 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
HOW IS CARE COORDINATED?
Care is coordinated by the Chronic & Complex Care Coordinator who:
· (with the persons’ consent) works with their General Practitioner and other health and community care providers to address care needs and design a plan of care
· involves the client and their carer in Care Planning
· monitors the effectiveness of services
HOW MUCH DOES IT COST?
There is no cost to the client for ongoing Care Coordination provided under the Care Coordination Program but there may be a cost for care provided by other service providers.
The involvement of the clients’ General Practitioner in Case Conferencing and Care Planning may attract a fee under the Medicare Benefits Schedule and other normal billing practices may apply.
WHO CAN REFER?
· Anyone can refer a client to the Care Coordination Program
· Referrals from clients and carers require a doctor’s or health professional’s referral to confirm their diagnosis
Referrals are made directly to the Chronic & Complex Care Coordinator:
Coffs Harbour Community Health Centre:
Ph: (02) 66 56 7814
Port Macquarie Community Health Centre:
Ph: (02) 65 88 2650
Taree Community Health Centre:
Ph: (02) 65 92 9647