Friday, March 12, 2010

Healthy@Home

Working with local GPs, the Healthy at Home (H@H) nurses promote and support optimal chronic disease risk factor management for people at risk of hospitalization.

The H@H program is funded by the Department of Human Services through Eastern Health. It is a Hospital Admission Risk Program (HARP), offering Chronic Disease Management. Nurse case managers coordinate care for people who live in the eastern region who have chronic conditions and complex needs and who have frequent hospital admissions or are at risk of hospitalisation.

What’s On Offer?

H@H aim to help people self manage their chronic conditions such as:

• Cardiac disease
• Diabetes
• Respiratory problems
• Multiple chronic and complex conditions

A registered nurse care coordinator augments the GP care by helping patient to:

• Recognise if their condition is deteriorating and help to prevent a hospital admission
• Advise patient and family on how to manage their conditions – as a ‘health care’ coach
• Manage medication issues
• Ensure good communication between patient and doctors
• Manage risk factors, give advice and support
• Ensure medical appointments and tests occur as planned – even attending them with the patient
• Linking the patient to appropriate community services

GPs are supported in care coordination and referral including use of GP management plans and team care arrangements.

This free service is available for people living in the eastern suburbs with chronic and complex conditions.

Referrals can be made by GPs, practice nurses, practice managers, hospital staff, patients, carers and family members.