Connecting Care Coordinator: Brandi Cole CNC (LGAs of Sydney City, Leichhardt, Marrickville)
Phone: 8752 4931
Mobile: 0459 826 880

Connecting Care Coordinator: Stefan Nynycz CNC (LGAs of Ashfield, Burwood, Canada Bay, Canterbury and Strathfield)
Phone: 8752 4931
Mobile: 0459 827 615

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Connecting Care

The current aims of the program are to improve communication across Primary and Secondary Care and to support patients with chronic diseases to navigate the health system. We support GPs by coordinating care for patients with one or more of the following:

• Congestive Heart Failure
• Coronary Artery Disease
• Chronic Obstructive Pulmonary Disease (COPD)
• Diabetes
• Hypertension

Patients can be referred from 16 years old (15 years old if Aboriginal).

Care Coordination can include a wide range of activities

• Locating and engaging non government organisations (NGO’s) to provide services to patients in their homes
• Referring to existing chronic care programs (such as heart failure or respiratory programs)
• Refer patients for ACAT assessments and or case management services
• Assist patients in understanding their chronic health condition and self management.
• Assist in arranging transport services for specialist and clinic appointments.
• Short term review and monitoring of management plans.

The Care Coordinator will work collaboratively with the GP and patient in accordance with the shared care plan. The patient’s GPMP and/or TCA become a central part of the coordination. Patients are assessed by Connecting Care Coordinators to determine if they would benefit from the program. Patient consent will also need to be obtained.

Patients can be referred by:

• GPs, if the GP is of the opinion that the patient who has one of the listed chronic diseases is at risk of a hospital admission or already has multiple hospital admissions.
• By Hospital clinics / departments

GPs can refer patients to connecting care by either:

• Faxing referral form (available on CSGPN website) directly to secure fax: 9009 0790
• Phoning Stefan Nynycz on Ph: 8752 4923

Templates for Referral

Connecting Care Referral form for Medical Director
Connecting Care Referral form for Best Practice
Connecting Care Referral form (manual)

Useful Links

Connecting Care Ministry of Health NSW:
http://www.health.nsw.gov.au/cdm/severe_chronic_disease_management_program.asp
Chronic Disease Management (CSGPN):
http://csgpn.org.au/services/info/chronic_disease_management/
Aboriginal Health (CSGPN):
http://csgpn.org.au/services/info/aboriginal_health/