Keeping our community out of hospital

Introducing a new community navigation program aimed at supporting people living in the community who have had a recent admission to hospital with dyspnoea (i.e. shortness of breath) due to a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and/or Congestive Heart Failure.

This program, in partnership with Melbourne Health, North Western Melbourne Primary Health Network and Cohealth, aims to improve patient care, outcomes and pathways for our shared communities via a community navigator to avoid hospital re-admissions.

This program works by having the community navigator receiving referrals from our HARP complex care team to support clients to maintain strong community connections and to keep the client living safely and independently in their own home.

The service includes a social and wellbeing assessment, development of goal directed care plan and connection to community based programs, based the identified needs of the client.

Some examples include:

• Identification of a skills gap or interest
• Referral to the local neighbourhood house to develop these skills (e.g. improve tech skills to increase social connectivity with family
• Assistance to connect to allied health supports (e.g. exercise group program run by physiotherapist)

The Community Navigator will also work closely with the clients GP to ensure that a holistic approach to their care is undertaken at the community level.

This new pilot program will be run for 12 months. We look forward to seeing how the program is received and will give an evaluation update, so keep your eyes peeled for what is to come!