Western HealthLinks is a program within the Chronic and Complex Care division that aims to support patients at risk of unplanned hospital admissions, to self-manage their health conditions and spend more healthy days at home. The program integrates hospital, ambulatory and community services to improve patient and health service outcomes. The model of care represents best practice for chronic condition management and provides cohesive and coordinated care from hospital to home. On July 1st 2021 Western Health transitioned to solely managing the HealthLinks program following a five year partnership with Silver Chain Group.
Model of CareIn Hospital- HealthLinks patients are identified on admission and are engaged in the program
- Patients are identified as high, medium or low risk taking into account their medical, debility and psychosocial factors to ensure resources and assistance is provided to those patients most at risk of re-presentation
- Inpatient Care Coordinators liaise with community Care Coordinators to ensure smooth transition of care
- The patient's GP will receive a comprehensive care plan and discharge summary from the hospital admission
In the Community
- Patients who are identified as medium or high risk are allocated a Care Coordinator to support the self-management of their health conditions, ensure linkages to community services and ongoing monitor and support
- Care Coordinators will develop a comprehensive care plan with the patient and their family in conjunction with the patient's GP and treating team
- Patients and carers will be supported with access to a registered triage nurse 24 hours per day, 7 days per week via the 1300 229 656 phone number
- The Priority Response Assessment (PRA) service provides rapid clinical assessment and intervention in the patients home to prevent an unplanned presentation to ED or admission to hospital
- Specific assistance in the home will be provided by Western Health Community Services including Nursing, Medical, Allied Health, Pharmacy and Psychosocial support.
Patient EnrolmentPatients cannot be referred to the HealthLinks program. Patients are identified according to the Department of Health (DH) algorithm which identifies patients at risk of readmitting to hospital based on several variables including:
- Age
- Number of presentations to the ED
- Number of admissions to an acute inpatient ward
- Chronic and Complex Illness (Charlson Comorbidity Index)
Further InformationFor further information regarding current inpatients who are enrolled in HealthLinks please liaise with the ACE inpatient Care Coordination team who are onsite and can assist with any enquiries. For enquiries regarding HealthLinks patients in the community, please email the HealthLinks Care Coordinators on
[email protected].
HealthLinks Enrolled patients, carers and health professionals can contact the 24/7 phone service for non-emergency medical advice on 1300 229 656.
For any other enquiries or issues relating to HealthLinks, please contact the HealthLinks and Integrated Care manager Cath Grant on 0466 469 372 or [email protected]
