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Our service specialists provide a person-centred approach that builds independence, and provides a positive experience for the client and their carers. This can include:

• Holistic assessment in the hospital to identify risks, protective factors, and needs for assistance with activities of daily living.
• Transitioning back to home planning including engagement of informal supports.
• Plan implementation which can include:
  – liaison with transport providers
  – organising home assistance as required (e.g. unpacking, washing, light shopping, arranging prescriptions and meals and light housework)
  – promoting access and communication between supports such as GP or specialist appointments
  – post-discharge welfare calls to see how the client is going
  – home visit for clients assessed at high risk and without family support
  – linking to immediate additional supports e.g., Home Medication Review, OT Assessment
  – providing relevant information to clients and carers
• Sustainability Planning:
  – brief care coordination, referral and linkage to community supports and appropriate services e.g. My Aged Care, social, welfare and community providers
  – communication with GPs, specialists, and the client’s personal support network.

We can help people in the process of being discharged from hospital and who meet one or more of the following criteria:

• They are living with three or more chronic health conditions/comorbidities
• They are at risk of readmission to hospital after transitioning home
• They would benefit from short term follow-up support

AND they are also residents of one of these local suburbs::

• Hunters Hill
• Lane Cove
• Mosman
• North Sydney
• Northern Beaches
• Ryde
• Willoughby

*Clients may not be eligible if they receive a service package which already provides a comprehensive support service component, such as COMPAC, TRANSPAC, CHSP, HCP, NDIS etc.

Talk to our friendly team for more information and to discuss access to the program.