An innovative pilot program is helping Canberrans with a chronic condition to ensure that they are accessing the services they need after being discharged from The Canberra Hospital.
Capital Health Network (CHN) Chief Executive Ms Gaylene Coulton said the ACTPHN’s Transitions of Care pilot program is supporting people with a chronic condition to better understand their condition and the support services available to meet their needs now and in the future.
“When people return home from hospital they often feel overwhelmed, forget what they’re meant to do and don’t know the local services available or anticipate the services they may need in the future. We’re helping clients and their carers link with and set up ongoing practical support. For example, we helped one client access My Aged Care to arrange someone to take them grocery shopping and access community transport,” said Ms Coulton, CHN Chief Executive.
The ACTPHN’s Transitions of Care team is empowering clients to take control of their condition and helping them to navigate the health care system.
“Many of our current clients are living with a chronic respiratory disease or a cardiac condition, or are older people who have had a fall. The program is open to people over 40 years who meet our criteria,” said Ms Coulton.
“We’re linking clients in with condition-specific support groups and chronic care programs. These offer valuable opportunities like health coaching and information to better understand their chronic condition,” said Ms Coulton.
The ACTPHN Transitions of Care team believes it is essential that the GP is at the centre of the client’s care.
“We really encourage clients to see their GP once they return home from hospital. Their GP is central to managing their care and to monitor changes in their chronic condition over time,” said Ms Coulton.
The pilot was established in collaboration with ACT Health and The Canberra Hospital after the ACTPHN’s Basic Needs Assessment identified gaps in the client’s understanding of the health services required once they returned home from hospital. The pilot is running until 30 June 2018 and is supported by funding from the Australian Government under the PHN Program. For more information, call 02 6287 8015 or toc [at] chnact.org.au.
Capital Health Network is the ACT’s primary health network supporting health professionals to improve the coordination of care so that patients receive the right care in the right place at the right time.