Programs - Chronic Disease Management

Connecting Care – NSW Health Severe Chronic Disease Management Program

Kathleen Ryan – Severe Chronic Disease Liaison Officer  

Phone: 02 6884 0197

The Connecting Care Severe Chronic Disease Management Program’s (SCDMP) aims to better connect general practice, specialist medical, acute hospital and community health services to provide improved patient centred coordinated care for patients with one or more of the following Chronic Diseases

1. Diabetes
2. Chronic Obstructive Pulmonary Disease
3. Coronary Artery Disease
4. Congestive Heart Failure
5. Hypertension, and

Who are 16 years and over and at high risk of unplanned hospitalisation or presentation to Emergency Departments.

NSW Ministry of Health - Connecting Care Program overview http://www.health.nsw.gov.au/cdm/severe_chronic_disease_management_program.asp

The local Connecting Care Program will be concentrate on two main areas

1. Improved Information Management to advance communication in the care and coordination of patients enrolled in the program across the acute / primary heath care sectors, and

2. Add capacity within General Practice to support patient care coordination, planning, monitoring and patient self management.

Resources

• AHP Services Directory..\..\Program\Service Directory\Service Directory Dubbo Nov 2010.pdf

Templates

• Connecting Care Registration Form for Best Practice, M/D and hard copy

Create link to website connecting care templates

• Patient Information card S:\PROGRAMS\Chronic Disease Management\Connecting Care Program\Program\Templates\LHD\CC Cards GP.doc

Contact

Kathleen Ryan ‘Connecting Care’ Liaison Officer on phone 6884 0197 or email This e-mail address is being protected from spambots. You need JavaScript enabled to view it

Pieta Harrison ‘Connecting Care’ Registered Nurse Dubbo Base Hospital phone: 6885 8797 or email This e-mail address is being protected from spambots. You need JavaScript enabled to view it