Keeping Well in Community Directorate

About our Directorate

The Keeping Well in Community Directorate supports people in south west Sydney to access the health services they need to stay healthy in the community.

Our Goal is to connect people to the right care and community supports and improve collaboration between services. By doing this, we can improve their experience of healthcare and make sure all their needs are met.

Our Mission is to support individuals with challenging health issues or disabilities. We do this by:

Helping our patients find and access the health and social services they need
Supporting our patients to make important decisions about their health
Giving education and tailored health information to improve self-management
Helping the health system respond better to the needs of our patients and local community

Our Team:

Nursing
Project Officers
Aboriginal Health Workers
Administration Officers
Allied Health (Counsellors, Social Work)
Medical (Doctors and Specialists)

Our Services:

The services we offer are listed in the table below.

We give care from and to community health centres, hospital wards, homes, and residential aged care facilities (RACFs).
For more information and contact details, please click the service name.

Service	Details
Keeping Well in Community Care Coordination and Navigation Program A 12-week program to help people with their health and prevent hospital visits	Advice and support Goal setting and planning Health assessments Resources Service linkages e.g. NDIS, My Aged Care
Disability Resource Team Services to help people with a disability using the health system	Advice and support Advocacy for carers Discharge planning Education and information
Specialist Intellectual Disability Health Team Services to help improve the experience of care for people with intellectual disabilities	Advice and support Health assessments Health care plans and recommendations Resources Training and education for health professionals
Paediatric to Adult Transition Care Service Support for people aged 14-25 with chronic and complex health issues transitioning to adult health services	Education Referrals Support transitioning to adult services
Out of Hospital Care (OHC) Program Packages to help prevent people going to hospital	Short-term home services to help with personal care, domestic chores, meals, transport and in home respite Short-term services to help people in the late stage of their illness with daily living tasks
Sexual Health Free services to test and treat sexual transmitted infections, HIV or other blood borne viruses	Counselling Health checks Health education and information Needle and syringe program PrEP medication Testing and treatment Support programs Immunisation (Gardasil)
Triple I Contact point for patients, carers and health professionals who need referrals to Primary and Community Health services	Aboriginal Chronic Care Program (ACCP) Care Finder Child and family health nursing Community nursing Community wound assessment team Direct access colonoscopy clinic Out of hospital care packages Palliative care home support Specialist aged care and rehabilitation team Community Older Persons Intervention and Liaison Outreach Team (COPILOT) PEACH Palliative Care Program
Youth Health Specialist services for disadvantaged and at-risk young people	Case management and coordination Counselling Health checks Health education and information Needle and syringe program Support programs Immunisation
WHIN Program Support for children and young people in primary and high schools across south west Sydney	Early access to care Health promotion (education and information) Health assessments Referrals
Specialist Menopause Service Virtual care service for women with severe pr complex menopause symptoms	Health assessments Management/treatment plans Education and training for primary care services

To access Keeping Well in Community services, you must:

Live in south west Sydney (refer to map)
Meet the eligibility guidelines

We can support you if:

You are a young person
You need help moving from child to adult disability services
You need help with a health condition to prevent future hospital visits
You need help with tasks at home after a recent hospital stay
You have an intellectual disability and need help taking care of your health
You need help with testing and treating a sexually transmitted infection, HIV or other blood borne viruses

How to Get in Touch:

Keeping Well in Community services are available from 8:00am-4:30pm, Monday – Friday (excluding public holidays). You can contact the services directly to find out more information.

Please note, referrals for the Out of Hospital Care program can only be made by health professionals from a hospital or community-based health team.