Hospital Discharge and Care Coordination Services
Description of Services
SNHN has commissioned two service providers – PCCS 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:
- Have suspected or diagnosed dementia
- At risk of admission to hospital or readmission to hospital following discharge.
- A person with three or more chronic or complex health conditions/comorbidities
- Would significantly benefit from short-term follow-up support
- People not currently enrolled in a Transitional Aged Care Program
- 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:
- 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.
Primary and Community Care Services (PCCS): 02 9477 8700 (Ryde, Hunters Hill, Lane Cove & Willoughby, Mosman, North Sydney & Northern Beaches). View referral form here.
Just Better Care: 0437 522 258 (Hornsby & Ku-ring-gai)