SESIAHS Connecting Care Program

NSW Health Severe Chronic Disease Managment Program - Connecting Care

As part of the response to the Government's Caring Together: The Health Action Plan for NSW, it was recommended that the NSW Health system provide improved integrated care for patients with chronic disease and pursue a coordinated care model to strengthen the role GPs in parallel with public hospital and community sector. In response, NSW Health has made available to Area Health Services funding for the establishment and delivery of Regional Chronic Disease Management Services (Connecting Care) across NSW under the framework of a new Severe Chronic Disease Management or Connecting Care Program.

SESIAHS approach – a coordinated, integrated effort

Chronic disease management is not new to SESIAHS. While all chronic diseases are different and need to be treated and managed using disease specific evidence based practice, care for all conditions should include:

• Goal setting and self-management support
• Provision of holistic care
• Early identification and management of related or co-occuring diseases;
• Monitoring ant determined intervals;
• Referral and team based care as appropriate; and
• Effective partnerships across the entire health and non-health related system
  

Clients

For the initial phase of the project the following patients will be targeted:

• Clients over 65 years old and Aboriginal clients over 45 years with established chronic disease (within specified target disease groups – cardiac, respiratory and diabetes conditions) and co-morbid conditions
• Clients experiencing three or more hospital presentations over the previous twelve month period as a result of established chronic disease
• Clients with established chronic disease at risk of hospitalisation for exacerbation of their disease process
• Clients with end stage or severe disease processes.

Contact

Nick Rosser, Chronic Care Coordinator at Sutherland Division of General Practice on phone 9545 3533 or email nrosser@shiregps.org.au

Linda Soars, CHN, Chronic Care Partnership Manager Linda.Soars@sesiahs.health.nsw.gov.au