Chronic Disease Management Service

Information for Health Professionals

The Chronic Disease Management Service is available 8am-8pm, 7 days

Tel: 1300 792 755, select "Option 2"

Fax: (02) 4253 0355

VeCC's Chronic Disease Management Service supports patients with life limiting chronic illness by providing patient-centred care and health coaching interventions empowering patient engagement in their health care decisions. Patients are also provided with remote monitoring of their blood pressure, oxygen levels, temperature, blood glucose levels, weight, and symptoms allowing real-time assessment by clinicians. 

Patients are in the Chronic Disease Management Service for generally between 6 days to 6 months and:

  • Assessed initially at their closest Community Health Centre with a nurse or allied health team member
  • Provided with equipment and education at their initial assessment (see details below)
  • Asked to complete observations on a regular basis, ranging from daily to weekly, depending on their care pathway
  • Have a video call weekly, fortnightly or monthly (depending on their care pathway) with a nurse or allied health team member.

Referral criteria

The following patients can be referred to the VeCC Chronic Disease Management Service:

  • Patients with chronic and acute respiratory disease(s)
  • Patients with mild to moderate decomposition of heart failure
  • Patients completing RCCP and/or Heart Failure Service who may benefit from additional monitoring or support
  • Patients who may be supported with Care Navigation, including accessing supports through Multicultural and Aboriginal services, or via Social Prescribing
  • Patients with chronic disease requiring end of life care 
  • Patients residing in a High Level Residential Aged Care Facility
  • Patients with cognitive deficits impacting treatment engagement, including those not able to be supported to utilise technology without the help of a carer
  • Patients who live outside of the Illawarra or Shoalhaven
  • Crisis care.

 

Referrals to the Chronic Disease Management Service

1. Choose your referral method:            
            ˃ eMR referral: go to "order" list, type "community health ISLHD"
            ˃ Email referral: ISLHD-AccessandReferralCentre@health.nsw.gov.au
2. The referral will be triaged by the Nurse Unit Manager and the VeCC Medical Officer
3. The VeCC will contact the referring team to accept the patient
4. Once care is accepted, the referring team should call 1300 792 755 (option 2) to speak to:
            ˃ A medical officer for clinical handover (mandatory)
            ˃ Similar process for nursing handover (mandatory)
            ˃ Up-to-date discharge summary (strongly encouraged)
5. If the patient requires antibiotics to be administered at home, please refer to Hospital in the Home (HITH) via a separate email.

 

Monitoring patients 

The VeCC team provides patients with the equipment required to monitor their health:

VeCC equipment for patients to monitor their health