St Vincent’s Hospital is implementing a chronic care service

St Vincent’s Hospital Chronic Disease Care Coordinators Service is implementing the ‘Planned Care for Better Health’ strategy to target locally vulnerable groups of individuals with chronic conditions at high risk of unplanned hospital admission or ED presentations.

Who do they see?

Community based clients living with COPD/Diabetes/Chronic Heart Failure/Ischaemic Heart Disease who are at high risk of hospital presentation and are willing to participate in improving their own health management.

What do they DO?

  • Help people to learn more about their health problems and to increase their health literacy through “one on one” health education and coaching.
  • Link individuals to services to help and support their health management and safety at home.
  • Work with people to help them to better understand and manage their health needs through the use of self- monitoring, health change recognition and use of health “Action Plans.”
  • Liaise between GP’s, specialist doctors and other service providers to help the person to maintain and attend appointment schedules, treatments and support services.
  • Help individuals understand the medicines they are prescribed & the benefits of adherence.

What they DON’T do?

Wound dressings, catheter care, medication administration, daily monitoring of client’s health, infusions of any kind, personal or domestic care.

Who can they refer?

The client, a family member or carer and any healthcare professional involved in the client’s care.

For further info:

Tel: 8382 1450

Email: svhs.chronicarecoordination@svha.org.au