HIP Complex Care Services – Chronic Disease

Service overview

The Chronic Disease team is a multidisciplinary team that provides care coordination, disease-specific intervention and support to clients with complex needs to assist them in achieving their healthcare goals.

We specialise in the assessment and management of chronic lung disease, heart disease, diabetes and HIV; however also provides care coordination for clients with other chronic conditions and complex health needs.

The team assists clients to improve their understanding of their disease, identify signs and symptoms, improve compliance with treatment and reduce the impact of the disease on function, activity, independence and wellbeing, thereby improving their self-management skills. The team also provide medical support via rapid access clinics and home visits.

Team members

  • Registered nurses (general, cardiac, respiratory & diabetes educators)
  • Physiotherapy
  • Occupational therapy
  • Dietitians
  • Speech Therapy
  • Social work
  • Psychology
  • Medical specialists (Respiratory, general medicine, endocrinology & infectious diseases)
  • 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 – 12 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, 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

HIV is a state wide services (exempt from geographical boundaries)

Referral process

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

Fax (03) 9231 2202

Contact details

Phone enquires via HIP Central 1300 131 470