Hospital Discharge and Care Coordination Services

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.
KinCare logo small  Just Better Care logo small
Cluster Map LCN

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:

  • 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)