New process for At Risk Program

7th November 2018

GPs need to be aware of the protocols surrounding the integrated care of patients at risk of re-hospitalisation.

All patients identified as at-risk upon presentation or admission to hospital may be screened using the Chronic Conditions Screening tool (CCoPS) to help identify further support requirements.

Following completion of the CCoPS screening, you will receive correspondence about patients who have been identified as at-risk of hospitalisation.

You will be encouraged to review the list and add or subtract patients who you feel may or may not be suitable for the intervention outlined. You will also be asked to share care plans with Primary and Community Health nursing teams.

For more information read the At Risk program document.


For more information download this document

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