Helping Local Residents With Chronic Disease

Photo from Left: Marisa Di Serio, Norma Weir & Peter Bunge
Thursday, 11 May 2017
Portland District Health’s Hospital Admission Risk Program (HARP) is helping local residents with chronic diseases to improve their health and spend more time at home.

While the program generally helps people with chronic health conditions such as chronic heart or respiratory diseases, HARP clinician Norma Weir concentrates on supporting those with social and emotional problems and helps them to set and achieve goals.

Ms Weir and her colleagues in HARP aim to help local people to avoid unnecessary trips to hospital. She has a background in welfare and qualifications including a Bachelor of Arts, Bachelor of Social Welfare, a Graduate Diploma in Family Therapy and a Masters in Applied Gerontology.

I talk to people about what they’re finding difficult to manage at home and then try to link them to community supports, such as home help, district nursing, counselling or aged care assessments, Ms Weir said.

We then work through the process of setting and achieving goals.

The role is very fulfilling and greatly appreciated by clients. It involves a lot of listening about what people want for themselves and providing a good shoulder to lean on, Ms Weir said.

Ms Weir is joined in the program by fellow HARP clinicians Marisa Di Serio and Peter Bunge.

HARP clinicians conduct home-based visits and aim to reduce avoidable hospital admissions and emergency department presentations by care coordination for clients in the community, providing education and support to the client and their carer, promoting self-management through care planning, improving access to local services, and working collaboratively with local GPs to enhance patient care and support.

Those most likely to benefit from this integrated care include people with chronic heart disease, or chronic respiratory disease and those with complex needs requiring integrated care.

Anyone can refer to HARP, including GP or physician, community-based services and health workers.

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