Service transition and exit is part of the continuum of care. Providing clients and service providers with clarity is a key element in managing the transition and exit process, so as to optimise the client’s care and expectations.Go to Transition and Exit policy (for internal staff)
The following triggers will prompt service transition and exit from our Care Coordinator service:
Go to the Client review meetings page in the chronic disease resource centre to see how these are utilised to plan a client’s transition and exit from the service. Coordination of the transition and exit is carried out by the Care Coordinator in partnership with the client (and their carer and family if appropriate) and in accordance with the care planning and care coordination policy. All Care Coordinator clients will be reviewed at least every six months (or when requested by the client) against the transition and exit triggers.Re-entry into the Care Coordinator service is based on level of need and the Priority of Access and Waitlist Management policies. Care Coordinators will be responsible for determining if a client would benefit from re-entry into the service.
The recall and reminder system offers systematic preventative care for clients, determined by clinical need. It is a system which provides for the ongoing care of clients, including regular health screening and chronic disease management by proactively enhancing return visits. A recall and reminder system forms an important part of the planned management of client care, particularly for clients with a chronic health condition. Go to the Reminder and Recall policy (for internal staff only)