HealthCare to Community

The HealthCare to Community team is a patient-centred, hospital-based service at Armadale Health Service.  We are an interdisciplinary team of allied health and nursing backgrounds.  

A targeted approach is used to focus on patients at risk of hospital readmission.  This includes patients with chronic diseases as well as patients with multi-disciplinary complex needs.  We conduct a thorough assessment, liaise with the multidisciplinary team, provide education on chronic disease self-management and ensure patients are linked with appropriate services in the community.

Our aim for care coordination is to:

• Improve the assessment of care needs.
• Improve communication regarding care provision.
• Facilitate access to required services.
• Support complex patients along the continuum of care.
• Provide post-discharge support to patients who have complex needs.

Our team is establishing links with local community services to ensure our patients are linked in with the appropriate services to:

• Enable optimised patient care in the community, reducing dependence on hospital based care.
• Facilitate seamless transition between services.
• Support patient to manage their health needs in the community.