KWIC Care Navigation and Care Coordination Program

About our Program

Keeping Well in Community (KWIC) Care Navigation and Care Coordination is a health program offered by South Western Sydney Local Health District (SWSLHD).

We can support you if you need extra help to look after your health at home. That way, you don't need to go to hospital as often, or for as long. We do this by helping you find the services and support you need to understand more about your health conditions and how to manage them.

Our Patients

We support people who:

  • Are aged 16 years or older,
  • Live in south west Sydney,
  • Have challenging or chronic health conditions, and
  • Are not connected to the right care to look after their conditions.

You can enter your address here to see if you live in south west Sydney.

What is Care Navigation and Care Coordination?

Care Navigation helps you find the right health and social care services. For example, if you have a long-term illness, you might need different types of services and advice. Care Navigation helps you find and use these services.

Care Coordination helps you manage care from different health services, like your doctor, hospital, physiotherapist, and dentist. The goal is to improve your overall health. Care Coordination also looks at the mental, social, and behavioural factors that can affect your health. This works well for people with long-term health conditions.

What is a chronic condition?

A chronic health condition is a long-term illness that lasts for 3 months or longer and can get worse over time. There is usually no cure, but there are treatments and lifestyle changes you can make to control your condition and feel better.
Some examples of a chronic health condition are:

  • Diabetes
  • Arthritis
  • Mental Health (depression, anxiety)
  • Respiratory disease (lung problems)
  • Renal disease (kidney failure)
  • Cardiovascular disease (heart problems)
  • Back problems

What to expect:

  • The program goes for 12 weeks, however you can opt out earlier if you feel like it isn't working for you.
  • You are allocated a KWIC nurse who will support you throughout the program.
  • You will have a health assessment over the phone to help your KWIC nurse understand what matters to you most and how we can support you (for example, seeing a specialist about your health condition, or finding out more information about your medications).
  • Your appointments will be over the phone (telehealth) unless a home visit is needed. Your KWIC nurse will make this decision during your health assessment.
  • We will teach you how to look after your health. We can send information and resources through a platform called GoShare which you can access on your phone or email. Or, we can post information to you if you don't have a mobile device.
  • We work with your GP (doctor) to make sure all your needs are met, including helping you find a GP if you do not have one.
  • At the end of the program, we will ask you to complete a survey to help us improve our service.
  • If there are still health needs that have not been met or you haven't achieved your health goals, you can re-enrol into the program.

How to access our Program

There are three ways you can access the Keeping Well in Community Care Navigation and Care Coordination program.

  1. You can make a self-referral. If the KWIC program sounds like it may work for you, you can call us on 0499 693 145. A KWIC nurse will ask you some questions over the phone to understand your needs. They may offer you enrolment in the program. KWIC CNCC Enquiry Form
  2. We may call you. If you have recently been to an Emergency Department or hospital, you may get a phone call from our team. We call patients who are at a higher risk of returning to hospital to see if we can help them look after their health in the community.
  3. You might be referred into the program. Your GP (doctor) or healthcare provider may call our team to see whether the program may work for you.

Contact Information and Opening Hours
Our hours are between 8:30am and 4:30pm, Monday to Friday (excluding public holidays).
Phone: 0499 693 145
Email: SWSLHD-IntegratedCare@health.nsw.gov.au


Keeping Well in Community Resources
KWIC Patient Brochure
Health Professional Information (for GPs and primary care providers)
KWIC Referral Form
KWIC CNCC Winter Strategies