Care Coordination

Integrated Care for People with Chronic Conditions

This program helps people with chronic conditions to live well in the community. We provide person-centred care that is coordinated and tailored to the needs of an individual.     

Our team

You may be supported by:

• a Registered Nurse
• a Social Worker

What we do

• Health coaching to motivate and encourage the behaviour and lifestyle changes that help you to stay healthy.
• Care navigation to link you up with community services.
• Care Coordination between your doctor and other services to improve access to care.

Our clients

Are people over 16 years of age (over 15 for Aboriginal or Torres Strait Islander people) living in the South Eastern Sydney Local Health District with complex, chronic conditions.

How do you access this service?

People who are admitted to hospital or emergency departments are automatically referred in to this program if they meet the entry requirements. You may be referred if you have been in hospital before and have ongoing health concerns.

A Registered Nurse will contact you over the telephone to talk about the program and ask for your consent to enrol.

More information

Contact Integrated Care on 02 9540 8175.

Health professionals can call our Care Coordinators at St George and Sutherland Hospitals on 02 9540 8167 or War Memorial and Prince of Wales Hospitals on 02 9369 0128 to discuss client eligibility for the program.