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Discharge Follow Up and Care Coordination Services for people at Risk of Hospitalisation or Re-admission

Discharge Follow Up and Care Coordination Services for people at Risk of Hospitalisation or Re-admission

Are you concerned about your patients with chronic and or complex care needs?
SNPHN has commissioned Kincare and Just Better Care to support GPs and other community based services to coordinate care for patients that are otherwise at risk of being hospitalized.

This includes access to nursing and other allied health services.

Patients must be at high risk of hospitalization within the next 12 months based on assessment using one of following tools:

  • Harp score ≥24
  • AUSDRISK Tool Score ≥12
  • AACVD risk ≥15
  • 3 or more chronic conditions / comorbidities
  • Frailty screening score ≥3
  • Hospitalised in the previous 12 months

For more information on how to refer to Kincare and Just Better Care https://sydneynorthhealthnetwork.org.au/about-us/commissioning/commissioned-services/#hospital-discharge-program  or email dclark@snhn.org.au.

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