Our Care Coordination Programs

Assisting clients with a chronic condition to manage their health in a way that results in optimal health outcomes.

Hunter Primary Care understands that patients can have complex and challenging needs.

Our care coordination programs are aimed at patients with complex needs and can reduce patient and carer stress and improve patient wellbeing.

Care Coordination domains of focus:

  • Health and service navigation
  • Skill and technique acquisition
  • Self-monitoring and health insight
  • Social integration and support

Care Coordinators are health professionals with experience in the community and general practice, who have a wealth of knowledge about local public, community and private healthcare services in their region.

Our Care Coordinators will facilitate the appropriate service delivery for a client following assessment, goal setting and care planning. It involves linkages with other service providers, the efficient use of resources and regular review.

Care Coordinators will conduct a comprehensive assessment in the client’s home, assist them to actively participate in their plan of care, and help them to understand why and how to access necessary services for their condition.

Our current programs 

Our past experiences have been working in collaboration with Hunter New England Local Health District.

HNELHD – Chronic Disease Management Program
This program was a chronic disease care coordination program funded by NSW Health, and conducted in collaboration with Hunter New England Local Health District and Hunter Primary Care.
Hunter Primary Care targeted care coordination for eligible high risk patients. The program was staffed with registered nurses and occupational therapist care coordinators who liaised with GPs, practice staff and their chronic disease patients to assist in the management of their complex needs.

This program ceased in 2015.