Community Care Coordination

Community Care Coordination is a specialised short-term service that helps individuals living with chronic diseases and/or complex needs to better understand their health.

We educate people about their chronic condition and provide tips and strategies on how to self-manage their health. 

The goal of the service is to increase people's independence in the community and reduce their risk of being admitted to hospital.

How our team can help you 

• We ensure you have appropriate ongoing care to support your health and wellbeing.
• We provide personalised care, based on your individual needs.
• We work together with you and your other healthcare providers to ensure you receive consistent, well-rounded care.
• We help identify any barriers that may have prevented you from accessing proper care and work with you to create a sustainable, ongoing care plan.
• We provide disease education and self-management skills.

Inclusion criteria

To be eligible for the Community Care Coordination service, you must:

• have had one or more avoidable hospital admissions in the past 12 months
• be at least 18 years old
• have multiple treating teams
• find it difficult to self-manage your health
• have faced health literacy barriers
• have minimal or fragile supports
• identify as part of a priority group (e.g. Aboriginal and Torres Strait Islander people).

Exclusion criteria

You are not eligible for the Community Care Coordination service if:

• you are an active inpatient (including subacute wards, bed substitution programs) or on the Transition Care Program
• you are receiving other active services (e.g. acute mental health, acute palliative care, residential aged care)
• you are under 18 years old
• you live outside the Western Health catchment
• you have no care coordination goals (e.g. you’re actively self-managing)
• your hospital admissions are related to unavoidable causes (e.g. emergency surgery, elective admission).

Please note: For diabetes education, please refer to the Diabetes Clinical Nurse Consultants

Our Care Coordinators will:

• make an initial phone call to get your consent and schedule a visit to your home
• work with you to define and achieve goals in managing your chronic conditions
• build your confidence in managing your health, medications, and appointments
• work with other health professionals who are part of your care team
• ensure that your home environment is safe and can best support your health.

Western Health staff can refer to Community Care Coordination using the Community Access e-Referral in BOSSNET.

Access the Community Services e-Referral instructions

If your referral meets our criteria, a clinician will contact you to arrange an assessment.

We accept referrals by GPs or other health professionals and community service providers. 

Please complete our referral form and fax it through to (03) 8345 6529.

All referrals must include:

• medical history details
• current medication list
• information on NDIS or Home Care Package (if any), with Case Manager details
• alternative contact details for patient (next of kin or carer)
• GP details.

If you have an enquiry about our Community Care Coordination program, please give our team a call and we’ll be happy to assist.

Phone: (03) 9055 2746
Fax (for referrals): (03) 8345 6529
We are open Monday to Friday, 8am – 4:30 pm

Frequently asked questions: 

Is there a cost for the Community Care coordination service? There is no cost to patients for our Community Care Coordination service.