Services

As part of the 50 Lives 50 Homes project, the After-Hours Support Service (AHSS) provides nursing and psychosocial support after hours, that integrates with the case management and tenancy support provided by organisations participating in 50 Lives 50 Homes. The AHSS is a critical element in enabling 50 Lives 50 Homes to sustainably house and support the most vulnerable rough sleepers by extending the capacity of existing service providers by providing follow-up services in evenings and on weekends.

As part of the 50 Lives 50 Homes project, the After-Hours Support Service (AHSS) provides nursing and psychosocial support after hours, that integrates with the case management and tenancy support provided by organisations participating in 50 Lives 50 Homes. The AHSS is a critical element in enabling 50 Lives 50 Homes to sustainably house and support the most vulnerable rough sleepers by extending the capacity of existing service providers by providing follow-up services in evenings and on weekends.

This activity is for the employment of a full-time Project Officer focused on chronic disease in the Midwest region, and is being undertaken in partnership with WA Country Health Service (WACHS) Midwest to support the WACHS Chronic Conditions Prevention and Management Strategy 2015-2020 as well as WA Primary Health Alliance’s (WAPHA) Integrated Chronic Disease Care (ICDC) Activity in the Midwest.

The activity provides education and support for non-oxygen dependent clients with Chronic Obstructive Pulmonary Disease (COPD) admitted to Joondalup Health Campus (JHC), to improve self-management. The Health Coordinator (HC) integrates client’s post-discharge care with primary health and community based services for up to six months. In addition, the HC collaborates with JHC Respiratory Physicians to provide (GP) education, with the aim of improving care and management of COPD patients in the primary care setting.

Clinical Care Coordinator: The Clinical Care Coordinator will provide care coordination service to Integrated Team Care eligible Aboriginal and Torres Strait Islander people with chronic disease/s who require coordinated multidisciplinary care as detailed within their Care Plan. These Care Coordinators are coordinators for the Integrated Team Care Service in their geographical location, and will link to ICDC for Allied Health Services as required.

Clinical Care Coordinator: The Clinical Care Coordinator will provide care coordination service to Integrated Team Care eligible Aboriginal and Torres Strait Islander people with chronic disease/s who require coordinated multidisciplinary care as detailed within their Care Plan. These Care Coordinators are coordinators for the Integrated Team Care Service in their geographical location, and will link to ICDC for Allied Health Services as required.

The Clinical Care Coordinator provides care coordination service to Integrated Team Care eligible Aboriginal and Torres Strait Islander people with chronic disease/s who require coordinated multidisciplinary care as detailed within their Care Plan. These Care Coordinators are coordinators for the Integrated Team Care Service in their geographical location, and will link to Integrated Chronic Disease Care for Allied Health Services as required.

The Integrated Chronic Disease Care program provides clinical care coordination for vulnerable and disadvantaged persons who have a chronic condition such as diabetes, and/or respiratory disease. By using a multi-disciplinary team-based approach involving GP referral, care navigation and access to health professionals, that is supported by telehealth services in remote locations. The program aims to improve health outcomes by promoting improved health literacy, consumer education and the development of self-management plans.

The Integrated Chronic Disease Care program provides clinical care coordination for vulnerable and disadvantaged persons who have a chronic condition such as diabetes, and/or respiratory disease. By using a multi-disciplinary team-based approach involving GP referral, care navigation and access to health professionals, that is supported by telehealth services in remote locations.The program aims to improve health outcomes by promoting improved health literacy, consumer education and the development of self-management plans.

The Integrated Chronic Disease Care program provides clinical care coordination for vulnerable and disadvantaged persons who have a chronic condition such as diabetes, respiratory and/or cardiovascular disease. using a multi-disciplinary team-based approach involving GP referral, care navigation and access to health professionals, that is supported by telehealth services in remote locations.

The Integrated Chronic Disease Care program provides clinical care coordination for vulnerable and disadvantaged persons who have a chronic condition such as diabetes, respiratory and/or cardiovascular disease. using a multi-disciplinary team-based approach involving GP referral, care navigation and access to health professionals, that is supported by telehealth services in remote locations.

The Integrated Chronic Disease Care program provides clinical care coordination for vulnerable and disadvantaged persons who have a chronic condition such as diabetes, respiratory and/or cardiovascular disease. using a multi-disciplinary team-based approach involving GP referral, care navigation and access to health professionals, that is supported by telehealth services in remote locations.

The activity helps persistent pain sufferers improve self-management of their pain through expert education, individual case management, support, goal setting and improved use of community healthcare services. The program is designed so that participants can explore a range of different strategies for living well; leading to reduced reliance on medication for pain management, reduced requirements for emergency care and participants not requiring referral to higher level of hospital based care. The program also builds capacity in the local primary care sector, to provide improved chronic pain management for all clients.

The activity helps persistent pain sufferers improve self-management of their pain through expert education, individual case management, support, goal setting and improved use of community healthcare services. The program is designed so that participants can explore a range of different strategies for living well; leading to reduced reliance on medication for pain management, reduced requirements for emergency care and participants not requiring referral to higher level of hospital based care. The program also builds capacity in the local primary care sector, to provide improved chronic pain management for all clients.

The activity helps persistent pain sufferers improve self-management of their pain through expert education, individual case management, support, goal setting and improved use of community healthcare services. The program is designed so that participants can explore a range of different strategies for living well; leading to reduced reliance on medication for pain management, reduced requirements for emergency care and participants not requiring referral to higher level of hospital based care. The program also builds capacity in the local primary care sector, to provide improved chronic pain management for all clients.

The activity helps persistent pain sufferers improve self-management of their pain through expert education, individual case management, support, goal setting and improved use of community healthcare services. The program is designed so that participants can explore a range of different strategies for living well; leading to reduced reliance on medication for pain management, reduced requirements for emergency care and participants not requiring referral to higher level of hospital based care. The program also builds capacity in the local primary care sector, to provide improved chronic pain management for all clients.

Integration of a non-dispensing pharmacist (practice pharmacist) into a General Practice multidisciplinary team with an overall goal to improve patient health outcomes and provide effective and efficient care, through QUM (Quality Use of Medicines). The pharmacist delivers clinical pharmacy and education services tailored to the needs of the individual General Practice (using the Pharmaceutical Society of Australia (PSA) needs assessment protocol) through a coordinated, collaborative and integrated approach. The pharmacist also works closely with and provides a key point of liaison for community pharmacies to ensure continuity of care.

Integration of a non-dispensing pharmacist (practice pharmacist) into a General Practice multidisciplinary team with an overall goal to improve patient health outcomes and provide effective and efficient care, through QUM (Quality Use of Medicines). The pharmacist delivers clinical pharmacy and education services tailored to the needs of the individual General Practice (using the Pharmaceutical Society of Australia (PSA) needs assessment protocol) through a coordinated, collaborative and integrated approach. The pharmacist also works closely with and provides a key point of liaison for community pharmacies to ensure continuity of care.

Primary Care at Home (PCAH) aims to improve access to primary health care for vulnerable people. Nurse practitioners work with clients of selected community and social service organisations to undertake a health assessment, develop an individualised plan and link the person to a regular GP. Nurse practitioners go to the client’s home and work collaboratively with the client’s community support worker.

The role of PCAH is to provide primary health care to eligible community service organisation (CSO) clients in collaboration with the client’s community support worker. The primary health care is delivered by nurse practitioners, nurses, or allied health employed by (or contracted to) the Silver Chain Group.

Primary Care at Home (PCAH) aims to improve access to primary health care for vulnerable people. Nurse practitioners work with clients of selected community and social service organisations to undertake a health assessment, develop an individualised plan and link the person to a regular GP. Nurse practitioners go to the client’s home and work collaboratively with the client’s community support worker.

The role of PCAH is to provide primary health care to eligible community service organisation (CSO) clients in collaboration with the client’s community support worker. The primary health care is delivered by nurse practitioners, nurses, or allied health employed by (or contracted to) the Silver Chain Group.

This service provides after hours General Practice consultations in the Armadale area located nearby to the Armadale hospital with the intention of provding patients access to GP consults as an alternative to presenting directly to the emergency department.

This program provides clinical care coordination and self-management support for metropolitan domiciliary oxygen clients, with advanced respiratory disease. Respiratory Liaison Nurses (RLN) connect clients to community-based services, to ensure a seamless transition from tertiary hospitals and access to support during advanced stage respiratory disease. The RLN ensures effective communication between community and hospital-based services to achieve best care. Eligible clients receive telehealth monitoring to identify clinical deterioration and promote self-management. If required, this may lead to referral to an appropriate clinical service.

This program provides clinical care coordination and self-management support for metropolitan domiciliary oxygen clients, with advanced respiratory disease. Respiratory Liaison Nurses (RLN) connect clients to community-based services, to ensure a seamless transition from tertiary hospitals and access to support during advanced stage respiratory disease. The RLN ensures effective communication between community and hospital-based services to achieve best care. Eligible clients receive telehealth monitoring to identify clinical deterioration and promote self-management. If required, this may lead to referral to an appropriate clinical service.

This activity provides a strategic approach to the prevention and management of chronic conditions in the South West through the implementation and coordination of evidenced based and person centered strategies which increase self management and minimise preventable hospitalisation.