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Chronic Disease Support:

Primary Care at Home (PCAH)
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Health Navigator
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Care Plan Support and Coordination Service
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St Patricks Centre
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Primary Care at Home (PCAH)

The Primary Care at Home (PCAH) program is a non-urgent service for vulnerable and disadvantaged adults with chronic health conditions.

Services will be provided by Nurse Practitioners and Registered Nurses in the clients’ safe place whether that be their home, hostel or community residential facility, or partner organisation facility.

Referral criteria

Eligible:

  • Have a diagnosed or suspected chronic condition (including physical and mental health conditions) or are at risk of developing one
  • Are disengaged with primary care – ie. does not have a GP or only sees GP for prescription; reliant on drop-in services
  • Aged 18 years or over
  • Resides in the Perth metropolitan area (from Two Rocks to Pinjarra and Wooroloo to the east)
  • Client is aware and consenting to the referral.

Not eligible:

  • Persons receiving Home Care Package Level 3-4

Geographical availability

Metropolitan WA:

  • All metropolitan areas.

Cost

No cost to client.

Program is funded by the WA Primary Health Alliance (WAPHA).


How to refer

Referrals can be received from any community organisations. Referrals cannot be received from GPs, in patient hospitals, or self referrals.

  1. Check referral eligibility criteria.
  2. Fill in the PCAH referral form.
  3. Send referral form either via:
  4. For any referral enquiries, please call to 1300 300 122 and ask to speak to our Case Coordinator or Program Manager Primary Care and Chronic Disease, available Monday to Friday from 8.00am to 4.00pm.
  5. We will make contact within 7 days of receiving a referral.
  6. For more information, refer to our referrer brochure and client flyer.



Health Navigator

Silverchain offers a telehealth co-ordination service that supports self-management of chronic conditions: diabetes, heart failure, heart disease and COPD or any long-term lung disease in the Wheatbelt, South West and Great Southern WA regions.

Referral criteria

Eligible:

  • Aged 18 years or over.
  • Has one or more of: diabetes, heart disease, heart failure, chronic lung condition or two or more risk factors.
  • Contactable via telephone.

Geographical availability

Metropolitan WA:

  • Not available

Country WA:

  • Wheatbelt regions
  • South West regions
  • Great Southern regions

Cost

No cost to client.


How to refer

Anyone can refer to this service, including self-referrals.

  1. Check referral eligibility criteria.
  2. Fill in the Chronic Disease Support referral form and send via:
  3. For any referral enquiries, please call 1300 300 122 and ask to speak to our Health Navigator team or Lead Chronic Disease Co-ordinator, available Monday to Friday from 8.00am to 4.00pm.
  4. Timeframes for response will be based on clinical need.


Care Plan Support and Coordination Service

The Care Plan Support and Coordination Service is a free service where Silverchain registered nurses provide support to patients living with mental health and/or drug and alcohol issues, who also have long term health conditions such as asthma, chronic pain, diabetes, cancer, heart, or lung disease.

Referral criteria

Eligible:

  • aged 18 or over
  • attends a GP practice in the City of Wanneroo
  • experiencing mental health and/or alcohol and other drug related problems as well as long term health conditions such as asthma, chronic pain, diabetes, cancer, heart, or lung disease.

Geographical availability

GP needs to be in City of Wanneroo. Client can reside anywhere. 

Cost

No cost to client.
Program is funded by the WA Primary Health Alliance (WAPHA).


How to refer

1.    Check referral eligibility criteria.
2.    Fill in the referral form either on you practice software or on the editable PDF referral form
3.    Send the completed referral form either via:

4. For any referral enquiries, call 1300 300 122 and ask to speak to our Program Manager Primary Care & Chronic Disease, available Monday to Friday from 8.00am to 4.00pm or email WACarePlanSupport@silverchain.org.au
5. For more information refer to our referrer information sheet and client brochure.


St Patricks Centre

A nursing clinic provided at St Patrick’s Community Support Centre.

Referral criteria

Eligible:

  • aged 18 or over
  • consents to service.

Geographical availability

Clinic location: 12 Queen Victoria Street, Fremantle 6160 

Available Monday to Friday, 8.30am to 1.00pm

Cost

No cost to client.


How to refer

1.    If you do wish to refer, please complete this referral form
2.    Send the completed referral form either via:

4. For any referral enquiries, call 1300 300 122 and ask to speak to our Program Manager Primary Care & Chronic Disease, available Monday to Friday from 8.00am to 4.00pm.