Chronic Care Coordinator

  • The Chronic Care Coordinator provides a range of services including:

     

    • Working with the Diabetes Educators and HARP team to provide improvements in the coordination of clients with a chronic condition in coordination and collaboration with clinicians, eg Podiatry, Diabetes Educator and Dietetics
    • Promote and support clients to achieve optimal health and wellbeing, and assisting with the adjustment to living with diabetes.
    • Provision of assessment and nursing care including health assessment and development of client centred goals for care plan providing follow-up review of goals.
    • Weekly contact with practice nurses at Hamilton Medical Group to share information regarding clients involved in a General Practice Management Plan (GPMP). This is a government funded program that provides five free visits to nominated clinicians a year.
    • Provision of support and assistance to clients that present to the centre with problems related to diabetes, which do not require them to be seen by a diabetes educator eg meter problems
    • Work with diabetes educators to assist with the implementation of the Let’s Talk Diabetes Program for people with newly diagnosed Type 2 diabetes or have not had diabetes education in the past.

     

    Work on promoting clients to attend recommended reviews of care by sending out recall letters. Includes follow up by phone.

     

    Referral

    Follow up through Diabetes educator