Complex Care Coordinators

The Complex Care Coordination Service is a seven day a week hospital based service at Armadale Health Service (AHS). We are an interdisciplinary team of allied health and nursing professionals.

A targeted approach is used with a focus on patients with chronic diseases particularly Chronic Obstructive Pulmonary Disease (COPD), Congestive Cardiac Failure (CCF) and Diabetes (type 1 and 2) as well as patients with complex needs. We conduct a thorough assessment, liaise with the multidisciplinary team, provide education on chronic disease management and ensure patients are linked in with appropriate services in the community.

Care coordination provides support to both the person and the care process to ensure that needs are assessed holistically to facilitate access the right care, at the right time, in the right place and by the right provider.

Our aim for care coordination of chronic disease and complex care is to:

  • improve the assessment of care needs
  • improve communication regarding care provision
  • facilitate access to required services.

Our team is establishing links with the local community to ensure our patients are linked with the appropriate services to:

  • enable safe patient care in the community which reduces dependence on hospital based care
  • facilitate the seamless transition between services
  • support patient adequately to manage their health needs safely within the community.


Referrals are received from AHS medical, allied health and nursing staff.

Last Updated: 28/02/2022