We are experienced in supporting people, with their family and GP, through the NDIS application process. This includes the completion and submission of the NDIS Application Forms.
In addition, we can provide support in collaboration with your planner, coordinator, consultant and healthcare providers, (funded through your NDIS package) for many health related goals.
Disability Health Support is an NDIS approved provider. Fees for our services may be covered by your NDIS funding. For enquiries about if/how we can support you within the NDIS Scheme, call for a complimentary initial discussion.
Complex Case Management Sydney
Complex Case Management fills gaps in health care that are being created by changes in the health system and in the demographic of health consumers. For patients, their families and their providers, a qualified health professional acts as a Personal Case Manager who works to ensure comprehensive assistance and is on your side and by your side from the minute you contact us.
- complex case management involves supporting the health system’s most challenging patients by working toward the goals that the client, and their providers, identify as most likely to achieve health outcomes.
- With complex case management we work with health providers to achieve the best health outcomes
- One goal is to improve communication between the many doctors and the health services you will encounter.
- We employs specific strategies to prevent readmission, ED visits, and hospital stays that are either too long or too short for your circumstance.
a Our complex case management is utilised by clients with chronic and complex health problems (eg chronic disease), patients who struggle with understanding, coordinating and complying with treatment, lawyers and Guardians who have oversight of clients' health/well being and families who are unable to attend and monitor doctors' appointments or explore and monitor residential aged care.
Services we offer:
Make referrals and find specialist medical and paramedical providers.
We have an extensive network of contacts within the mainstream health services who we can recommend and collaborate with.
Address barriers to care.
Based on a patient’s transition barriers, including financial, caregiver, and medical complexity, the team will identify and obtain resources to minimize the barrier. If social barriers such as housing issues, financial limitations, lack of a decision-maker, or legal concerns are identified, the team collaborates with a social worker or lawyer as appropriate. If the barrier involves the patient’s lack of ability to make medical decisions our partnership with social work may include coordinating a family meetings, identifying and establishing an enduring guardian, or completing an advanced healthcare directive.
Improve handoffs.
We have various ways to hand off patients to the next level. Our absolute mantra is good communication. We can provide written reports, convene team and family conferences and follow through with clients during and after a transfer to ensure care is seamless.
If we’re involved, we stay involved until a successful transition has occurred and the patient and family no longer need our services. Complex case management entails fastidious planning and detailed record keeping. We don’t hand off to the team and walk away. We visit those patients in their homes or nursing facilities and communicate with staff caring for the patient, including nurses, providers, nursing home coordinators, and administrators.
Use readmission prevention strategies.
We focus on helping your medical provider in keeping non-hospitalized patients out of the hospital and preventing newly discharged patients from returning to the hospital.
Meet community partners.
We meet with individual community partners to explain our role, introduce ourselves, and to define our process of providing a more detailed handover.
Identify patient problems.
We speak with the patient and their supporters to establish achievable goals and the means to reach those goals.
Target length of stay (LOS).
We work with hospital based providers to focus discharge plans of patient readiness. Delayed and premature discharge are associated with poor outcomes and often result from a lack of momentum by doctors, pressure on hospital beds and a hospital's strategy to maximise its remuneration.
Hold weekly team consults.
We aim to have a clinical team meeting weekly with medical providers and family members to review progress, plans and discuss patient needs.
The team meetings can cover prognosis, readmissions, concerns, treatment options, and barriers. The goal is to come up with strategies to transition hospitalized patients without unnecessary delays or haste.
Services we offer:
Make referrals and find specialist medical and paramedical providers.
We have an extensive network of contacts within the mainstream health services who we can recommend and collaborate with.
Address barriers to care.
Based on a patient’s transition barriers, including financial, caregiver, and medical complexity, the team will identify and obtain resources to minimize the barrier. If social barriers such as housing issues, financial limitations, lack of a decision-maker, or legal concerns are identified, the team collaborates with a social worker or lawyer as appropriate. If the barrier involves the patient’s lack of ability to make medical decisions our partnership with social work may include coordinating a family meetings, identifying and establishing an enduring guardian, or completing an advanced healthcare directive.
Improve handoffs.
We have various ways to hand off patients to the next level. Our absolute mantra is good communication. We can provide written reports, convene team and family conferences and follow through with clients during and after a transfer to ensure care is seamless.
If we’re involved, we stay involved until a successful transition has occurred and the patient and family no longer need our services. Complex case management entails fastidious planning and detailed record keeping. We don’t hand off to the team and walk away. We visit those patients in their homes or nursing facilities and communicate with staff caring for the patient, including nurses, providers, nursing home coordinators, and administrators.
Use readmission prevention strategies.
We focus on helping your medical provider in keeping non-hospitalized patients out of the hospital and preventing newly discharged patients from returning to the hospital.
Meet community partners.
We meet with individual community partners to explain our role, introduce ourselves, and to define our process of providing a more detailed handover.
Identify patient problems.
We speak with the patient and their supporters to establish achievable goals and the means to reach those goals.
Target length of stay (LOS).
We work with hospital based providers to focus discharge plans of patient readiness. Delayed and premature discharge are associated with poor outcomes and often result from a lack of momentum by doctors, pressure on hospital beds and a hospital's strategy to maximise its remuneration.
Hold weekly team consults.
We aim to have a clinical team meeting weekly with medical providers and family members to review progress, plans and discuss patient needs.
The team meetings can cover prognosis, readmissions, concerns, treatment options, and barriers. The goal is to come up with strategies to transition hospitalized patients without unnecessary delays or haste.