Support for people with complex chronic disease (Integrated Chronic Care)
The Integrated Chronic Care team supports people on the Central Coast who have complex chronic (long-term) disease who need extra help navigating their care.
The service helps co-ordinate your care, set goals and support you to manage your condition day to day. This can help you stay well and avoid unnecessary hospital visits.
Care coordinators work with you, your carers and your health care team to help organise your care and make it easier to access health and community support services.
Who can access this service
This service may be suitable if you:
- Have one or more chronic diseases
- Need extra support managing your condition
- Have been in hospital or visited the emergency department often
- Would benefit from short-term support to help you organise your care and build confidence managing your health.
Support is provided for a short-term period, based on individual needs.
How this service can help
Care co-ordinators can
- Be a link between your GP, hospital and community health services
- Assess your health and support needs (including at home if needed)
- Work with you and your carer to set goals and develop a plan
- Help you feel more confident managing your health
- Help you understand what might be making it harder to stay well and how to manage it
- Help you access other health and support services
- Speak up for you and support you when needed
How to access the service
A referral is required to access this service.
Referrals can be made by:
- GPs
- Hospital teams
- Community health services
Contact
Referrals are coordinated through Community Health Access & Intake (CHAI).
Phone: 1300 725 565
Email: CCLHD-CommunityHealthReferrals@health.nsw.gov.au
Fax: 02 4320 9333
Useful links
Get Healthy NSW (free phone and online health coaching)
NSW Health – integrated care for patients with chronic conditions