Role of Community Services
The new model of care will be integrated with current community based chronic disease services including HealthOne and the Connecting Care Program to build capacity in the system to support care co-ordination, case management and direct clinical services (e.g. wound management, palliative care, incontinence) for those with chronic disease. Care Facilitators will work closely with chronic disease nurses, HealthOne and General Practice Liaison Nurses (GPLN’s) to facilitate appropriate community based care. Similarly, they will facilitate referral to level 2 and 3 care of the Connecting Care program when appropriate home based reviews and direct service coordination is necessary.