Program Officer         Sandy Johnston or Linden Harper                         

Working Days             Monday to Friday

Connecting Care is a coordinated and integrated effort that can assist with: 

• Goal setting and self management support;

• Provision of holistic care;

• Early identification and management of related or co-occurring diseases;

• Monitoring at determined intervals;

• Recall and review at determined intervals;

• Referral and team based care as appropriate; and

• Effective partnerships across the entire health and community system.

Patient Care

Managed By Connecting Care Coordinator Sandy Johnston at St George Division  

• Co-ordination and management planned around patient’s health needs and unplanned admissions to hospital

• Shared health information and health action plans that include all partners

• Support to access range of services for client self-management, such as health coaching.

Eligible Patients

Clients over 16 years old and Aboriginal clients over 15 years with established chronic disease and co-morbid conditions (cardiac, respiratory and diabetes)

Very high risk (three or more hospital admissions over previous twelve months)

Ineligible Patients

• In High Care Aged Residential Facilities

• Managed on a Stroke Pathway

• Advanced Dementia

• Malignant Disease

• Managed by Palliative Care teams

Resources

• Information Brochure

• Referral Form