Community health in Western Sydney

Our Aboriginal health services team support Aboriginal and Torres Strait Islander peoples at every stage of life. We offer programs to help close the health gap, including:

• support for long-term and complex health needs (Integrated Team Care program)
• a diabetes group to improve care and reduce unfair health outcomes
• mental health services, including help for mums and babies
• vaccinations and sexual health care
• youth health support.

We are based at Mount Druitt Hospital.

Find out more about our Aboriginal health services.

Our child and family health services promote the development, wellbeing and safety of children.

Our services are free if you have a Medicare card and live, work or study in the Blacktown, Cumberland, Parramatta or The Hills local council areas.

Find out more about our child and family health services.

Our chronic and complex care team provides community nursing and allied health support for older people.

We help people improve, recover or maintain their health and independence so they can stay living safely at home.

We focus on helping people regain or maintain their physical, thinking and daily living abilities.

Patients and carers are supported to take part in decisions about their care.

What we do

We provide:

• Assessment, treatment and ongoing support for people with long-term or complex health conditions.
• Help to maintain or regain independence, quality of life and wellbeing.
• Shared care plans developed with patients, carers, GPs and other health services.
• Coordination with hospitals, specialists, primary health and community services.
• Community-based palliative care for people who need end-of-life support.

How services are delivered

We offer care in different ways, depending on each person’s needs:

• home visits
• outpatient clinics or community health centres
• virtual (online or phone) care appointments.

Who can use this service

You may be eligible if you:

• Live in the Western Sydney LHD area.
• Are an adult with a chronic or complex health condition.
• Are aged 65 or over, or 50 or over if you are an Aboriginal or Torres Strait Islander person.
• Have trouble with daily activities such as moving, communicating, or caring for yourself.
• Live independently at home in the community.

Who provides care

Our team includes:

• registered and enrolled nurses
• nurse practitioners, clinical nurse consultants, clinical nurse specialists and nurse educators
• clinical psychologists
• dietitians
• occupational therapists
• physiotherapists
• podiatrists
• social workers
• speech pathologists.

Operating times

• Nursing services: 7 days a week, 7am to 10pm.
• Allied health services: Monday to Friday, 8am to 4:30pm.

How to refer

The Central Referral Service (CRS) is the main contact point. Anyone can make a referral, including patients, carers or health professionals.

• Phone: 1800 600 681 8am to 8pm, 7 days a week
• Email: WSLHD-CommunityHealth-ReferralService@health.nsw.gov.au

If the person is aged 65 years or over (or 50 years or over for Aboriginal and Torres Strait Islander people), referrals must go through My Aged Care.

In the My Aged Care portal, search for:
Allied health and community nursing and social support group WSLHD.

Chronic care services for Aboriginal peoples

The Integrated Team Care (ITC) program aims to improve health outcomes for Aboriginal and Torres Strait Islander people with chronic conditions through care coordination and support for self-management.

Find out more about the Integrated Team Care Program.

Because diabetes is a major health issue in Western Sydney, the Western Sydney Diabetes initiative aims to help more people stay healthy, prevent others from developing diabetes, and reduce the number of people at risk.

Find out more about Western Sydney Diabetes.

Western Sydney Local Health District (WSLHD) offers a Health Care Interpreter Service to help patients of Culturally and Linguistically Diverse (CALD) backgrounds and health staff understand each other clearly.

If a patient does not speak English well, a trained interpreter can help. Interpreters can join appointments in person, by phone, or by video, any time of the day or night, 7 days a week. The service is available in about 100 languages, including AUSLAN (Australian Sign Language) for Deaf patients.

Health Care Interpreters are professionally trained and certified by NAATI. They understand medical words and must follow strict rules to keep patient information private.

WSLHD rules say that professional interpreters must be used when a patient is not fluent in English. This helps keep care safe, clear, and fair. Family members, friends, or bilingual staff are not allowed to interpret, because this can lead to mistakes or misunderstandings.

Find out more about our Health Care Interpreter Service.

The Western Sydney LHD Hospital in The Home (HiTH) service delivers acute care in the community as a safe alternative to a hospital admission.

We’re here to provide you with the same quality care you’d receive in the hospital, right in the comfort of your own home. Our team of healthcare professionals will monitor your health closely, support your recovery, and ensure you have everything you need.

What to expect

• regular visits from our clinicians
• support with your treatment plan and medications
• guidance on managing your condition safely at home
• a contact number if you need help or advice

Your health and comfort are our top priorities.

How to access HiTH

Access is usually arranged through your hospital or treating doctor. If you or a loved one is currently in hospital and would benefit from HiTH, speak with your treating team about eligibility. Referrals are typically made by doctors, nurses, or discharge planners.

If you are in the community, your doctor can call HiTH on (02) 8838 6333 to discuss eligibility for admission to the service with our HiTH consultant.

Eligibility

Patients must meet specific criteria to be eligible. Typical conditions managed through HiTH include:

• Infections requiring intravenous antibiotics, including cellulitis, pneumonia, urinary tract infections.
• Chronic disease management and exacerbations, such as COPD flare-ups, heart failure.
• Post-surgical recovery and wound care.
• Other conditions as determined appropriate by your treating medical officer and the HiTH service.

Patients must be medically stable, have a safe home environment, and consent to regular visits by the HiTH clinicians.

Where care is provided

A person/patient admitted to the WLSHD HiTH service may receive their care:

• at home (this includes residential aged care facilities (RACF) and group homes)
• in a community setting
• ambulatory care setting
• at school or in the workplace.

Learn more about HiTH.

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Video transcript

Hospital in The Home - Margaret's story

Margaret O'Neil - HiTH patient

I had to have a hip replacement and went to Mount Druitt for the rehab afterwards. I found out about it, and they put my name forward for this program. The teams come in here to help me to get rehabilitation at home.

Gauri Miszka - HiTH Pharmacist

I thought it was incredible that in Australia there was a service where you could go into people's homes and treat them in the comfort of their own home and provide sort of holistic care for them and not just medical care, and I thought that was incredible.

Georgia Zarb - HiTH Registered Nurse

Being at Hospital in the Home, you actually see how they operate in their home environment, and you see a different side to your patients, so I really like that different aspect of patient care.

Perry Ileto - HiTH Registered Nurse

They like the service that we do, especially because they don't have to wake up early in the morning, at 4:00am in the morning, just to get OBS, so they're comfortable. That's what matters to them really.

Margaret O'Neil - HiTH patient

They're friendly. They also encourage a lot of,  to do all these exercises. I'd never have done them if they hadn't been here.

Rhiannon Dick - HiTH Physiotherapist

What patients like about being treated with Hospital in the Home, especially physio, is they don't have to return to the hospital to get treated, and they're able to complete the whole program in their home.

Kishan Manandhar - HiTH Registered Nurse

They're very welcoming. They enjoy us coming to their place. They like the fact that we call before prior seeing them, providing that patient-centred care that I feel a lot of the time we don't see on the wards, because we have that one-to-one interaction a lot of the time as well when we visit our patients.

Maria Navarro - HiTH Registered Nurse

They get treated in their own environment. It's less stressful for them because they are able to manage and carry on with their lives, so what we need to do, or what we do, is empower them out in the community.

Margaret O'Neil - HiTH patient

Yes, I would recommend the service to friends and anybody who's in the same position I've been in.

Angelia Bariuan - HiTH Respiratory CNC

It's very interesting to see patients and being able to care for them in their own home.

Sarbjeet Purba - HiTH Registered Nurse

When people give us positive feedback, I feel so good. I feel proud of myself and the service that we are changing people's lives on an everyday basis.

Rhiannon Dick - HITH Physiotherapist

After filming with Margaret, we caught up one more time, and she's now able to walk independently up and down her street, which she hasn't been able to do even prior to getting a hip replaced. She was extremely ecstatic to be able to now be more mobile in the community.

It's good to see patients, I guess, be able to achieve the goals that they want, and especially to help to know obviously we're improving patients’ quality of life while they're managing in the community.

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Video transcript

Hospital in The Home - Jeffrey's story

Jeffrey Brown - HiTH patient

I heard about the hospital in the home program when I was first admitted to Westmead Hospital 2 years ago. They told me it was possible for me to get out of hospital and have  nurses attend at home, so that's how I found out about the program.

Bhartiben Vekaria - HiTH Nurse Unit Manager

A lot of the patients get surprised that such a service does exist, first of all. But they're very impressed that all the treatments happen at home. They recover faster, which is what they really like about the service.

Varun Randhawa - HiTH Medical Officer

It's a pleasure to deliver life-saving treatment to patients at home, at an environment that they're comfortable with. I come to work every day and there's always a new challenge, there's always a new patient, there's always a new coordinated plan that we are liasing with the team to try to deliver to the patient to make sure that the patient's are well and he recovers.

Jeffrey Brown - HiTH patient

Well I had an absis on the bottom of my foot. I originally was on antibiotics on a drip. The Hospital in the Home provides a service where I can actually have a drip at home and have the bottle changed daily by one of the nursing staff. If the Hospital in the Home Service didn't exist, well I would have probably spent months in hospital, so the service to me is very convenient.

Justin Smith - HiTH Clinical Coordinator

HITH is a great service to use. They love being in the home environment and be able to see their family. Most importantly, sleep in their own bed and eat their own food.

Madhuri Bakshi - HiTH Registered Nurse

They are very appreciative of HITH nurses going to see them at rainy days, or you know winter days, or summer days.

Dr Ziad Basyouny - HITH Medical Officer

Most of our patients happy with the fact that they get treated at home, but when they get the treatment itself it's such a relief - now they can go on with a with their lives.

Tracey Gatt - HITH Wound CNC

Most of the feedback that we get from our patients is very positive that we're preventing them from going back to hospital and that we can provide the care for the patient in their home, which just allows them to be more comfortable in their home setting.

Jeffrey Brown - HITH patient

It's a much better option than being stuck in the hospital, mentally you feel so much better being at home and I think when you're mentally better off, it does help in your physical recovery, I really believe it.

Our Integrated Violence Prevention and Response Service provides counselling and support for people impacted by abuse, neglect, sexual assault and domestic violence.

Find out more about our violence, abuse and neglect services.

About our service

We provide support to clients after hospital discharge which provides flexible contact options, including:

• phone calls
• video conferencing
• email (for non-verbal clients)
• face-to-face visits at the client’s home or GP clinic.

This service is primarily nurse led model with different programs depending on the need and requirement of client:

• care coordination
• care navigation
• Aboriginal 48-hour follow-up
• risk of hospitalisation and post-discharge follow-up
• self-management support
• urgent cares services for residential aged care facilities 

Care Coordination Service

Our Care Coordination program provides person-centred support for clients with complex or ongoing health needs. The program helps ensure your care is well organised between your healthcare providers. This includes your GP, specialists, and community services.

Our team works closely with you to support your recovery and help you stay well at home. Support may include regular phone or video check-ins, home visits, and GP visits as needed.

Through Care Coordination, we aim to:

• support self-management and understanding of your care plan
• improve communication between care providers
• prevent unnecessary hospital visits or readmissions
• help you achieve your health goals.

You may benefit from Care Coordination if you:

• require short-term support regarding your recent hospitalisation
• find it difficult to manage or coordinate your care

Care Navigation Service

Our Care Navigation service is a telehealth-based program that supports clients, carers, and families after hospital discharge. The service helps you access the right health and community services, ensuring your transition from hospital to home is as smooth as possible.

Through phone or video consultations, our Care Navigation team will:

• Connect you with appropriate health and community services.
• Help arrange referrals and follow-up appointments.
• Support you in navigating the healthcare system.

You may benefit from Care Navigation if you:

• Need support with referrals or access to community or health services.
• Require help arranging follow-up care after discharge.

Aboriginal 48-Hour Follow-up Program

The Aboriginal 48-Hour Follow-Up Program provides culturally appropriate support to Aboriginal and Torres Strait Islander clients following hospital discharge. 

Eligibility

• Aged 15 years or older.
• Living with a chronic condition.

Program details

Follow-up calls are conducted by an Aboriginal Health Practitioner.

During the call, the practitioner will:  

• Review the client’s discharge summary.
• Ensure the client understands their post-discharge care plan.
• Identify any ongoing health or support needs.

Clients who require additional assistance with managing their health or accessing community services may be enrolled in the inTouch Community Care Program for ongoing support. 

Risk of Hospitalisation and Post-Discharge Follow-up 

The Risk of Hospitalisation (RoH) call is a check-in after someone leaves hospital. It makes sure the person:

• Has their discharge summary (the hospital’s instructions)
• Understands what it says
• Knows about any follow-up appointments or care they need

This call also helps decide if the person should join the InTouch Community Care Program for extra support.

Who is at higher risk?

Some people are more likely to go back to hospital. The program looks at things like:

• ongoing health problems (diabetes, asthma, COPD, heart disease)
• age (over 16 years, or over 15 for Aboriginal and Torres Strait Islander people)
• past hospital stays
• language or cultural background (CALD)
• other social factors that affect health.

Why this matters

Many hospital readmissions can be prevented. With good planning and follow-up, people can recover safely at home and avoid another hospital visit.

How follow-up works

After discharge, the team makes a phone call to:

• Answer questions about care.
• Check that instructions are clear.
• Fix any problems with the discharge plan.

This follow-up helps:

• People feel more confident managing care at home.
• Families and carers get the support they need.
• Reduce the chance of going back to hospital.

Self-Management Support (SMS)

Our care facilitator works closely with clients to set realistic, achievable goals and provides guidance and support to help them reach these goals. For example, if a client is unable to walk short distances to their letterbox, our care facilitator may refer them to a physiotherapist to develop a tailored plan.

By addressing individual needs and tracking progress, this support helps clients maintain positive health outcomes, stay motivated, and sustain long-term lifestyle changes.

Urgent Care Services for residential aged care facilities

The Urgent Care Service supports residents of aged care facilities in Western Sydney by making health care faster, easier to access, and more personalised.

What the service does

• Helps nursing home staff navigate health services and connect residents with the care they need, both inside the facility and in the wider community.
• Reduces delays and wait times by coordinating care, managing referrals, and ensuring timely access to services.
• Provides the right care, in the right place, at the right time, easing pressure on emergency departments.
• Supports aged care staff so they rely less on NSW Ambulance and Emergency Departments when hospital care isn’t required.

How it works

• Facilities can refer residents directly to the Urgent Care Service for timely medical assessment.
• Visiting Medical Officers (VMOs) provide online assessments to help prevent unnecessary ambulance call-outs or hospital transfers. After each consultation, a Clinical Summary of Care is sent to the facility to guide ongoing management.

Follow-up and continuity of care

• The service contacts the facility the day after any care episode to check on the resident’s condition and confirm the care plan developed by the VMO.
• For residents discharged from hospital, the team ensures the facility has received the discharge summary, updated medications, follow-up appointments, and addresses any concerns about ongoing care.

Referral Pathways  

inTouch accepts referrals through the following pathways:

• Self-referral – clients, carers/families, or aged care facility staff can call directly.
• GP referral – referrals made by the client’s general practitioner.
• Hospital referral – for client’s discharged or identified during hospital admission.
• Internal services – referrals from within the NSW Health District for client’s who reside within the Western Sydney LHD.
• External community services – referrals from community healthcare providers or support agencies

Contacting inTouch

inTouch Urgent Care Service for residential aged care facilities
Available Monday to Sunday, 8am to 8pm including public holidays 
Phone: 1800 600 681

inTouch Community Care, 48-Hour Follow-Up 
Available Monday to Friday, 8am to 4:30pm.
Phone: 1800 113 644

Our multicultural health teams work with communities and health professionals to make sure Western Sydney LHD services are culturally appropriate and easy to access for people from diverse backgrounds.

Our multicultural health services include:

• multicultural health at Auburn and Westmead
• multicultural health at Blacktown and Mt Druitt
• statewide and specialist programs
• Multicultural Access Project
• translation service.

Find out more about our multicultural health services.

New Street Services provide therapeutic services for children and young people aged 10 to 17 years who have engaged in harmful sexual behaviours towards others, and their families and caregivers.

Find out more about New Street Services.

Children and young people in out-of-home care (OOHC) often have high and unmet health needs and are more disadvantaged and vulnerable than other children.

NSW Health provides coordinated health assessments for children and young people aged 0 to 17 years in statutory OOHC living in NSW who are expected to remain in care for longer than 90 days.

Contact

Phone: (02) 9881 1200
Email: wslhd-oohchealthassessments@health.nsw.gov.au
Address: Mt Druitt Community Health Services, Corner Buran and Kelly Close, Mt Druitt NSW 2770

Find out more about the OOHC Health Pathway Program.

Our community palliative care team includes a range of qualified health professionals who provide coordinated, person-centred care in the community.

Find out more about our palliative care services. See the Central Referral Service (CRS) section on this page for referral information. 

Our population health team works to improve and protect the health of everyone in the Western Sydney LHD.

We do this by:

• promoting healthy behaviours and environments
• preventing illness and injury
• protecting the community from health risks.

Find out more about our population health services.

Our youth health services are funded by NSW Health and are available to young people aged 12-24 years, who are connected to the Western Sydney LHD catchment area.

All services provided by our youth health team are free and confidential. Services include:

• alcohol and other drugs
• sexual health
• mental health
• physical health
• homelessness
• basic needs.

Find out more about our adolescent and youth health services.

The Central Referral Service (CRS) is the single entry point for referrals to Western Sydney Integrated and Community Health.

CRS helps connect people with the right community health services. It accepts referral requests from general practitioners (GPs), NSW Ambulance, aged care facilities, hospitals, patients, families and other health professionals.

Referrals can be made for services such as:

• nursing
• speech pathology
• occupational therapy
• physiotherapy
• dietetics
• podiatry
• audiometry
• counselling
• supportive and palliative care.

CRS manages referrals for clinical programs including:

• chronic and complex services
• child and family health services
• residential aged care facilities
• movement disorders nurse practitioner service
• Aboriginal chronic care
• Aboriginal supportive and palliative care
• community palliative care.

Note: CRS does not provide clinical assessments or triage services.

How to refer

Self-referrals

Clients can refer themselves by calling the Central Referral Service (CRS) on 1800 600 681.

Our team will take your details and connect you with the right community health service.

Health professional referrals

Health professionals can contact the Central Referral Service for enquiries about Child and Family Health Services or Chronic and Complex Services.

• Phone: 1800 600 681
• Hours: 8am to 8pm, 7 days a week

A 24-hour voicemail service is available. Messages are usually returned within one business day.

How to send a referral

• Email: WSLHD-CommunityHealth-ReferralService@health.nsw.gov.au
• Fax: (02) 9881 7789

Referrals for older people

If your patient is:

• aged over 65 years, or
• aged over 50 years and identifies as Aboriginal or Torres Strait Islander

referrals must be made through My Aged Care.

In My Aged Care, our provider name is: Allied Health and Community Nursing and Social Support Group WSLHD

Phone: 1800 200 422
Online referral: My Aged Care – Make a referral

Why CRS asks for information

CRS collects referral information to check eligibility and allocate clients to the right service.
We ask about:

• personal and contact details
• family or support information
• legal or safety issues
• current health concerns.

Some of this information is required by the NSW Health and our funding bodies.

Contact us

Central Referral Service
Phone: 1800 600 681
Fax: (02) 9881 7789
Email: WSLHD-CommunityHealth-ReferralService@health.nsw.gov.au

Hours: 8am to 8pm, 7 days a week.