HIP Complex Care Services – Aged Care

Service overview

The Complex Care Aged Care team is a multi-disciplinary team that works with clients with aged-related issues, who exhibit complex health care and psychosocial needs, and chronic illness or conditions. This service improves health outcomes for these clients taking into account the progressive nature of health needs, deterioration in functional status or social issues. The Complex Care Aged Care team provides a care coordination service and works collaboratively with health and welfare agencies in the local community. This can include a timely access to a Geriatrician or Aged Care Nurse Practitioner review for people living in the community.

Care Coordination:  The care coordinator provides one main point of contact that assists the client, carer and/or family to navigate the service system and facilitates the provision of proactive care. This ensures:

  • Continuity of care
  • Integrated care
  • Communication between the client, carer and/or family and other health and social care providers is streamlined
  • Duplication of services and processes are minimised.

Team members

  • Registered nurses, including Nurse Practitioner
  • Physiotherapy
  • Occupational therapy
  • Dietitians
  • Speech Therapy
  • Social work
  • Psychology
  • Medical specialists (General medicine,  Geriatrician Medical Specialists )
  • Pharmacy

Service delivery

  • 5 day a week service within business hours
  • Number & frequency of sessions determined with client following a comprehensive assessment & goals setting
  • Program duration 1 – 6 months
  • Sessions available in the home & other community settings

Eligibility criteria

SVHM Primary Catchment: City of Yarra, City of Boroondara and southern part of City of Darebin.

Clients linked to SVHM through Specialist or Outpatient service, Social Work Dept. or a History of emergency or inpatient admissions, and residing within: SVHM Secondary Catchment (parts of Darebin, Moreland, Stonington & Melbourne)

Or as per case by case consultation with Manager

Referral process

Fax (03) 9231 2202

Referrals occur via email - HipCentralReferrals@svha.org.au

Contact details

Phone enquires via HIP Central 1300 131 470