Allied and Community Health Services

Continuing and Complex Care

The Continuing & Complex Care department consists of five programs:

Hospital Admission Risk Program (Complex Care)

A free, short term care program designed to improve health outcomes for people with chronic illness. If you have recently visited the hospital or Emergency Department, you will be assigned a care coordinator who will provide advice to manage your condition at home.

Residential In-Reach (RIR)

This program provides an alternative to emergency department presentations for people in residential aged care facilities (RACF’s). RIR aims to support clients and RACF staff to manage acute health issues when GP is unavailable. This includes phone support and nurse visits if required.

Post-Acute Care (PAC)

This program provides short-term services and support for those who need extra help at home after a hospital stay. This program aims to help people return to a normal lifestyle as soon as possible, and to avoid any unplanned return to hospital. This includes community nursing, personal care, home care and respite.

Transition Care Program (TCP)

This program aims to help older people (65 and older) complete their recovery following a hospital stay. The program can be provided in the community or in a residential setting. Each client will receive an individualised care plan and their length of time on the program is different for each person.

Geriatric Evaluation Management (GEM)

This program provides care where the primary goal is to improve the functioning of people with complex needs. GEM includes a personalised management plan with a focus on rehabilitation. GEM can be provided in a number of settings, including dedicated inpatient beds at the hospital or in your home.

How to book a Continuing and Complex Care service

Hospital Admission Risk Program: Referral is made by your GP or any health professional when you present to the Emergency Department or are admitted to hospital. Phone (03) 5622 6411 for more information.
RIR: Residential aged care staff to phone (03) 5623 0674.
PAC: Referral is made by hospital staff to the PAC service. Phone (03) 5624 0571 for more information.
TCP: The Aged Care Assessment Service (ACAS) assess and approve the eligibility of clients for the TCP. Phone (03) 5624 0576 for more information.
GEM: Referral is made by the hospital or other rehabilitation service. Phone (03) 5624 0576 for more information.