HealthCare to Community

INFORMATION FOR PATIENTS & CARERS

• The HealthCare to Community team is a patient-centred, hospital-based and outpatient service at Armadale Health Service.  We are an interdisciplinary team of allied health and nursing backgrounds, providing specialist support to patients with Chronic Heart Failure (CHF) and Chronic Obstructive Pulmonary Disease (COPD).  We also work with patients with complex care needs to optimise discharge from the hospital.  We conduct a thorough assessment, liaise with other members of the multidisciplinary team, provide education on chronic disease self-management, and ensure patients are linked with appropriate services in the community.
• If you receive an appointment with our HealthCare to Community outpatient clinic, you will have your appointment with our nurse who works closely with the AHS Cardiology and Respiratory team.  During your appointment we will discuss how you have been feeling since you have been discharged from our hospital and ways to improve your health which may include education about CHF and/or COPD, adjustments to your medications with the help AHS Consultants and handing over key information to your GP.  We may also refer you to community-based services to assist you further.
  • Outpatient Brochure (PDF 1MB)

INFORMATION FOR GENERAL PRACTITIONERS

• The HealthCare to Community team is a patient-centred, hospital-based and outpatient service at Armadale Health Service.  We are an interdisciplinary team of allied health and nursing backgrounds, providing specialist support to patients with Chronic Heart Failure (CHF) and Chronic Obstructive Pulmonary Disease (COPD).  We also work with patients with complex care needs to optimise discharge from the hospital.   We conduct a thorough assessment, liaise with other members of the multidisciplinary team, provide education on chronic disease self-management, and ensure patients are linked with appropriate services in the community.

CASE CONFERENCING OR PATIENT CARE TEAM MEETINGS

• A case conference is a meeting with the patient, the GP and the hospital to plan and monitor a patient’s care to ensure their needs are met through a collaborative and coordinated approach. This typically would include the patient’s GP, the patient and two additional health service providers, although the patient does not have to be present if they do not want to.
• It is claimable through MBS items 735, 739, 743 (GP initiated and organised with hospital participation) or 747, 750, 758 (hospital initiated and organised with GP participation).
• Our team will write to you to offer the option of a case conference for a particular patient.  We do this because it gives us the opportunity to handover key information to you and ensure that you can seek assistance from our outpatient nurses.  You are welcome to initiate a case conference with our team as well.
• You can do this via clicking this link to our form or email or phone us for more information (see ‘Contact Us’).
• More information about case conferencing via phone is available in the attachments - 
  • Case Conference Information Sheet
  • Outpatient Brochure (PDF 1MB)

ASSISTANCE FOR YOUR PATIENT WITH CHRONIC HEART FAILURE

• Local GPs can refer patient with CHF (etc) to the HealthCare to Community Outpatient Clinic for adjustments to CHF medications (for example, up titration of medications) and self-management education.
• Criteria for this referral is as follows:
  • Confirmed diagnosis by echocardiogram of Chronic Heart Failure (HFpEF, HFmrEF or HFrEF)
  • Patient resides in the AHS catchment (post codes: 6107-6112; 6121-6126; 6147; 6306; 6390)
  • Patient is willing to participate in a nurse-led clinic and attend appointments at AHS.
  • You can refer your patient via clicking this link to our form or email or phone us to discuss (see ‘Contact Us’).