Information for Health Professionals
The Community Chronic Care Program operates during business hours Monday to Friday
Tel: 1300 792 755, select "Option 3"
Fax: (02) 4253 0355
The Chronic Care Program is a person-centred, self-management program. The Chronic Care Team (CCT) provides support and education for individuals living with chronic illnesses, focusing on strengthening self-management strategies and optimising care to reduce the risk of avoidable hospital admissions. This is a goal-focused, time-limited program delivered over approximately 2–3 months. The team supports clients in setting and working towards personalised health goals, while coordinating communication between clients, healthcare providers, and relevant government services.
We offer non-pharmacological support for managing anxiety and breathlessness, culturally appropriate care and nursing guidance. The Chronic Care Program works collaboratively with a multidisciplinary team of professionals to achieve the best possible outcomes for people living with chronic conditions. The service also provides virtual education sessions on differing topics including falls prevention, benefits of exercise and staying active, emotional wellbeing, managing chronic health conditions.
What the Program Provides
- Initial assessment by a member of the multidisciplinary team.
- Individualised care planning based on patient goals and needs.
- Health coaching and self-management support.
- Access to online group education sessions designed to enhance patients' understanding of their chronic health conditions and self-management strategies
- Regular follow-up and coordination of care with relevant health services.
- Support to access community and specialist services where appropriate.
Referral Criteria
Patients may be referred if they:
- Consent to engage with the service.
- Are aged 16 years or older.
- Reside within the ISLHD catchment area.
- Have a chronic illness such as;
- Chronic Respiratory Disease (Chronic Obstructive Pulmonary Disease, Bronchiectasis, Asthma) in liaison with Asthma Clinical Nurse Consultant, the Respiratory Clinic or Pulmonary Rehab Program
- Heart Failure in liaison with Heart Failure Service
- Diabetes in liaison with The Diabetes Service
Exclusion Criteria
The service is not suitable for:
- Permanent Residents of Residential Aged Care Facilities.
- patients aged under 16 years
- Maternity Patients
- Patients with significant cognitive impairment that prevents engagement with the program and who do not have adequate carer support.
- Patients with ongoing engagement with alternative services e.g Dialysis, Oncology Treatment, Silverchain
- Inpatients, Rehab, Private or other facility
- Patients with Acute Coronary Events e.g. post PCI, PPM, ACS, Surgery
- Patients living outside the Illawarra or Shoalhaven regions.
- Patients requiring crisis or emergency care.
Referral Pathway
Referrals should be submitted to the Access Referral Centre (ARC). All referrals will be reviewed during weekly triage meetings to determine client suitability for the program.
Email: ISLHD-AccessandReferralCentre@health.nsw.gov.au