HARP (Hospital Admission Risk Program)

For Patients and Visitors

What is the Service?

Care coordinators are health workers who work with patients and their carers or family in the community to ensure that they receive the care and support that they want and need.

Care Coordinators do 3 important things. They:

  • Help patients and families to understand their medical condition, know how to take medications and follow other instructions.
  • Talk to all the Doctors and providers working with a patient to gather important health information and share it with the patient and family in a way that they can understand.
  • Link people to services and supports

What can I expect from the service?

Care coordinators will usually visit you at home. They will listen carefully to what you are worried about and work out a plan to help you and your family manage these things. They will also find answers to the questions that you have and check some key things that will help to keep you safe at home such as how you are taking your medications. They may also contact your GP to make sure she/he has all the information they need to help you to stay well.

What do I bring/need for my appointment?

If there is a family member or friend that helps you with your health, it would be really useful for them to be at the visit. An accurate list of medications, the name and clinic address of your GP and a list of any specialists and services that you visit would be really helpful.

Enquiries and Referrals:

Community Access:

Our offices are staff Monday to Friday 8:30 am -4:30pm

Free Call: 1300 128 539

Fax: 8405 8616

Email: Community. Access.Helpdesk@nh.org.au


 For Health Professionals

Service Overview

Care Coordination is offered by the Hospital Admission Risk Program (HARP).  Care Coordinators work with patients at risk of hospital readmission due to chronic disease, frailty or complex psychosocial issues.

Care Coordinators may have a nursing or allied health background. They undertake holistic assessment which identifies the concerns of the patient and family and key factors that place the patient at risk of unplanned readmission/ED attendance.  A care plan is developed which may include (but not limited to) referral to services, medication review, health-coaching and equipment provision.  Care Coordinators liaise with health providers working with the patient to ensure a single, cohesive history and care plan is available.

Inclusion criteria:

Hospital admission in the last 12 months

Risk of representation

Reside in Northern Health catchment

May live in the community or Residential Aged Care Facilities within forty minutes’ drive of Northern Health

Exclusion criteria:

Patients with acute psychiatric condition – please refer to an area mental health service.

How to Refer:

To refer, please contact the Community Access Service

Fax:                    8405-8616

Email:     Community.Access.Helpdesk@nh.org.au

Referral must include:

Past medical history including a current medication list

Specialists providing care to the patient (public and private)

Current community services/supports involved

Functional status and social history including NOK/key support person


Our offices are staffed Monday to Friday 8.30 am to 4.30 pm

Free Call:    1300 128 539