Care Coordination

Client Focused Care and Service Solutions

Care CoordinationThrough its effective referral management and screening process, including comprehensive assessment of client needs and coordination of service solutions, Care Coordination makes it possible for many people who would otherwise need residential care to stay in their own homes or community.

Care Coordination is underpinned by principles of:

  • Providing client focused care and solutions
  • Working in partnership with the client, families/whanau, carers, and their support network
  • Enhancing and optimising client independence
  • Sourcing integrated community based solutions
  • Providing standardised assessment
  • Elimination of duplication
  • Intersectoral collaboration
  • Nothing is too much trouble

Care Coordination’s range of services include:

  • Referral management
  • Care Management
  • Restorative packages of care
  • InterRAI assessment tools
  • Goal facilitation

Referral Management

Care Coordination manages referrals requiring access to community based health services funded by the District Health Board. The range of contracts and services covered within this function is based on the individual DHB requirements but may include District Nursing, Allied Health, Home Based Support Services and Acute Demand Services.

Care Management

Care Management involves a senior health professional with the advanced clinical judgement and expertise to comprehensively assess and plan care for clients.  This is done in collaboration with the clients, their family/whanau and other primary health care providers so the best options and outcomes can be achieved.

Key functions of Care Management include providing advocacy, expertise and advice to the community, administering the InterRAI MDS-HC suite of tools for assessment and care planning, defining collaborative care plans, liaising with all relevant care and support providers across all sectors e.g. Primary Health Organisations, Hospital & Health Services and non-government organisations to ensure integration across all sectors.

InterRAI Assessment Tools

Care Coordination has developed expertise in the use of interRAI using the InterRAI Contact Assessment and InterRAI MDS-HC tools.

The Contact Assessment (CA) can be done face to face or over the phone and takes about 30 minutes to complete. The outcome is a better understanding of the urgency of the service requirement and the type of service need.

The MDS-HC is a full and comprehensive assessment tool designed to be used in community environments on clients with complex needs. It is often referred to as the home care tool or HC and utilises information from a number of sources that may be involved in the client’s ongoing care.

Some of the services include:

  • community allied health services
  • community rehabilitation services
  • district nursing services
  • home based services, including home help and personal care assistance
  • access and entry to residential care
  • respite care
  • day care

The Care Coordination Centres are staffed seven days a week.

Hours of service:
8am-6pm Monday to Friday
8am-4pm Weekends/Holidays (Except Hutt Valley Service Coordination Centre)

There is also an on-call service for urgent matters

Canterbury Corporate Office

Download the Referral form

Canterbury District Health Board

24 McDougall Ave
PO Box 36126
Christchurch 8146

Phone 03 378 4020
Fax 03 355 5225
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Capital & Coast

Download the referral form PDF

Download the referral form electronic version

Capital & Coast District Health Board

10 Wi Neera Drive
PO Box 50544
Porirua 5240

Phone 04 238 2020 or 0800 282 200
Fax 04 238 2022 or 0800 282 202
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Hutt Valley

Download the referral form

Hutt Valley District Health Board

Pilmuir House, Pilmuir Street
PO Box 30658
Lower Hutt 5040

Phone 04 566 2226 or 0800 662 225
Fax 04 566 2227 or 0800 329 662
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