The team acts as a valuable resource to clinical areas regarding discharge options & community service/programs, especially in relation to patients with complex needs. Key work priorities of the team include the initial assessment & triage of all referrals received via the Continuing Care e referral system for patients who may require inpatient rehabilitation, residential care, transitional care or an Aged Care Consultancy Service.
A further role of the CCDT is Post-Acute Care (PAC) coordination. PAC is a DHHS funded program which provides community-based services to assist people to recuperate after leaving hospital with an aim to prevent hospital readmission. PAC provides a range of services; based on patient's individually assessed needs, such as nursing, physiotherapy, in-home respite, homecare & shopping. Services are generally of a short-term nature.
The Care Coordination and Discharge Team welcomes feedback about your experience.