Hospital Discharge and Care Coordination Services
Description of Services
SNHN has commissioned two service providers – KinCare and Just Better Care – to provide hospital discharge and care coordination services across the Northern Sydney PHN region. For service regions over the map below.
- Discharge Follow-up Service: a hospital to home transition service that is designed to reduce the likelihood of re-admission to hospital after discharge.
- Care Coordination Services: care coordination for patients that are otherwise at risk of hospitalisation, where short term management could be beneficial. Both providers can also work with a range of community and primary health providers to coordinate care for these patients.
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Eligibility Criteria
Discharge Follow-up Service:
Public and Private hospitals are eligible to refer the following patients to the discharge follow-up service:
- People who have suspected or diagnosed dementia
- A person with a chronic or complex health condition
- A person who is not receiving adequate support, and would significantly benefit from post-discharge follow-up at home within 24 hours
- Would significantly benefit from short-term follow-up support
- Are not currently enrolled in TACP/TRANSPAC
- Exhibit other characteristics to be agreed
Care Coordination Services:
GPs and other primary care based services can refer to care coordination services for patients at high risk of hospitalisation, determined by using one or more of the following tools:
- Harp score ≥24 (Chronic Condition Risk Calculator – Harp Tool)
- AUSDRISK Tool Score ≥12 (Ausdrisk Tool)
- AACVD risk ≥15 (Heart Risk Calculator)
- Frailty screening score ≥3: See Frailty Tools:
- 3 or more chronic conditions / comorbidities
- Hospitalised in the previous 12 months
How to refer
Referrals to the Discharge Follow-up Service can be made by Public and private hospitals.
Referrals to the Care Coordination Services can be made by GPs and other primary based care services.
Kincare: 1300 689 741 (Ryde, Hunters Hill, Lane Cove & Willoughby, Mosman & North Sydney, Northern Beaches)
Just Better Care: 0437 522 258 (Hornsby & Ku-ring-gai)