Comprehensive and Coordinated Primary care, and Chronic Disease Management services:
This service is coordinated by a full time care coordinator and CDM nurse.
Their role includes the identification, clinical management, recall and ongoing support of patients who require chronic disease management. This also includes patients who fall into the category covered by Annual Health Assessments (AHA), Disability AHA, Veterans Affairs CVC, and nursing home CMAs. The coordinators also support patients with access to social services such as:
- home help
- meals on wheels
- respite care
- Veterans affairs
- Taxi cards
- disability services
- ACAS services
- patient transport
The care coordinator also attends family conferences in nursing homes and the local hospital and reports back to the patient’s General Practitioners. Your doctor will be able to discuss your eligibility for a Care Plan and referral for allied health appointments under the Enhanced Primary Care arrangements. Our Care Co-ordinator is able to assist you in making these appointments and to answer any questions or concerns you may have.