Your Care
The client journey through the Healthy@Home Chronic Disease Service involves the following steps:
| Step 1: You are referred to the service. |
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| Step 2: Within four weeks you will be offered an appointment with a registered nurse. |
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| Step 3: At your first appointment a health assessment is done and a joint plan of care prepared. |
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| Step 4: You start putting your agreed plan of care into action. |
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| Step 5: You attend a follow up appointment in around two weeks to review your plan of care. |
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| Step 6: You will be offered a place in a self-management program, lifestyle group education and/or an exercise program. |
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| Step 7: You are supported in your self-management and plan of care with follow-up phone calls. |
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| Step 8: You complete the program and are provided with an ongoing plan of care and links to appropriate local services/programs. |
When you complete the program your ongoing plan of care will include:
- Information on your individual needs
- Goals
- Information on treatment
- Activities for you to do
This care plan gives you a clear outline how to continue with the self-management of your chronic condition.
You should remain in close contact with your GP who will periodically review your plan with you to provide you with the appropriate level of continual care.