Veterans are assigned a Case Manager who manages an assessment and treatment plan and coordinates care across services both internal and external to the Centre.
The Case Manager acts as a single point of contact for the veteran, their family and carers and primary healthcare professionals. The Centre provides individually tailored assessment, support and links to programs. Case Managers assist in the navigation of healthcare services to promote continuity of care.
The Case Manager supports the veteran to identify personal and treatment goals in conjunction with the Centre’s multidisciplinary team. The Case Manager and the veteran will have regular phone and face-to face-contact.
The Case Manager coordinates discharge planning and referrals to ensure the smooth transition of care into the community. A Telehealth case conference is scheduled between the veteran, their family and carers, their GP and the Case Manager to discuss the discharge plan and handover to community services. Case Managers follow up with the veteran at two weeks after discharge and again at three months post-discharge. These follow-up sessions also provide the veteran an opportunity to discuss their experience of and satisfaction with the Centre.