Seeking GP referrals for Complex Care patients

The Complex Care Coordination Team (previously known as HARP) is one of the teams based in the Health Independence Program (HIP) at Werribee Mercy Hospital.

Who are we and what do we do?

• We work with patients with complex care needs over the age of 18 who live in the Wyndham area, who are struggling to manage significant chronic diseases and/or psychosocial issues. This cohort is at risk of presenting to hospital, or have had avoidable hospital admissions over the past year.
• We are a team comprised of nurses and social workers. We act in the role of Care Coordinators. We have a flexible approach, visiting people in their homes if safe to do so, in centre or elsewhere if appropriate.
• We aim to prevent and/or reduce avoidable hospital admissions.
• We aim to provide a comprehensive and coordinated approach helping clients/patients manage their health at home. We provide education and follow up appropriate referrals. We can support patients to organise appointments and navigate the healthcare system. Sometimes we attend GP appointments to enhance coordinated care.
• We can assist our clients to access other HIP services, such as the geriatrician clinic, diabetes nurse, occupational therapy, community-based rehabilitation, continence clinic and pulmonary rehabilitation.
• We recognise the impact of psychological and social problems on people’s ability to manage their health. For example, we support people who are facing family violence, mental health issues, drug and alcohol use, homelessness. We acknowledge the profound impact that chronic disease has on people’s functioning and well-being, and support people to adjust to changes in their health.
• However, we are not a crisis or immediate-response service and we do not replicate other community services that can better meet the needs of a person.

Which patients might benefit?

The following patients might benefit from a referral to our service:

• Patients struggling to manage their chronic diseases, who may present to hospital or have frequent admissions that could be avoided, and/or may have number of social problems that are impacting upon their ability to manage their health conditions.
• Patients who have a disorganised, chaotic approach, or where you identify a chaotic systems approach to their healthcare and who require a more coordinated care approach.

 How to refer?

You can refer to the Health Independence Program using HealthPathways, or you can find the Health Independence Program Referral Templates on our referral page and fax to: 03 8754 3281 or email to [email protected].

For more information visit the Mercy Health HIP website, the Mercy Health Complex Care website or contact Brigitte Grant (HIP manager) or Cara Thompson (intake worker) on phone: 8754 3800 or via email: [email protected]