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Complex Care and Chronic Disease

Bendigo Health GP SCTT Referral Form
Referral Form for discharge planners, allied health works and nurses

Bendigo Health Referral Centre
Telephone: 1300 733 581
Fax: 1300 733 589 or (03) 5454 7099
Mail: PO Box 126, Bendigo, 3552

Our Services

Case Management Services (CMS)

Hours: Monday to Friday, 8.30am – 5pm
Phone: 5454 7833

Case Management Services provides support for aged and frail people, people with a disability or chronic illness, and their carers, to live independently in their local community.  The Case Managers are skilled professionals who use person centred principles to assist clients to identify, achieve and direct their care planning and coordination. Case Managers will also assist to manage client’s care packages. The Linkages Program is supported by funding from the Commonwealth and Victorian Governments under the HACC program. 

Diabetes Services

Hours: Monday to Friday, 8.30am – 5pm
Phone: 03 5454 9228

The diabetes service provides education and support for people with diabetes and their carers regarding self-management, lifestyle modification, equipment supply and maintenance. The service includes hospital inpatients and general community clients and includes a Continuous Glucose Monitoring System service, Paediatric and Adolescent Diabetes clinic, Diabetes in Pregnancy Endocrinology clinic, Initiation of insulin therapy and ambulatory stabilisation, and Health promotion activities and diabetes awareness workshops to community and service groups and schools. The diabetes service liaises with the individual’s general practitioner (GP) and other health professionals regarding patient care. 

Hospital Admission Risk Program (HARP)

Hours: 8.30am – 5pm
Phone: 03 5454 7045

HARP provides a co-ordinated team approach to managing people in their homes that have one or more chronic diseases and/or a complex illness. The HARP team is made up of a number of health professionals, which includes specialist nursing, occupational therapist, physiotherapist, psychologist, social worker and others.  The staff specialises in the management of chronic respiratory disease, asthma, including paediatric asthma, chronic heart disease, chronic kidney disease, diabetes, complex aged care issues and complex psychosocial needs. 

Transition Care Program and Restorative Care (TCP)

Hours: Intake - Monday to Friday, 8am – 4pm
Phone: 03 5454 9106

The Transition Care Program (TCP) program facilitates care for older people who have completed their hospital stay and need more time and support to make a decision on their long term aged care options. TCP provides older people with a package of services that includes low intensity therapy, eg physiotherapy and occupational therapy, as well as social work, nursing support or personal care. Restorative Care is a similar program that allows younger people to access the service, from hospital, from the emergency department and from their home. A multidisciplinary package of services is available. TCP and RC is a regional service and are provided in the community or is bed based. The service is provided to the individual seven days a week. 

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