Wellbeing and Health In-reach Nurse (WHIN) Coordinator Program Guideline and Model of Care.
Figure 3: Service cycle
Alternative text
The figure has a middle circle with the words Client and family surrounded by five circles representing a continuing cycle of steps
Activities for each of the steps are described below.
The wellbeing nurse explores issues and conducts assessments to identify the health and wellbeing needs of the client. The wellbeing nurse gathers the client’s information and medical history and other relevant information from the client and/or family members, other clinicians, school staff and medical reports as appropriate. Current supports and services the client is accessing or has received previously are identified and the client’s health and wellbeing needs assessed using the assessment tools endorsed for use for the WHIN Coordinator program if appropriate.
The wellbeing nurse works with the client and/or their family to identify goals to achieve for the client’s health and wellbeing. Goals are prioritised in collaboration with the client and/or family members based on the client’s and family members’ identified needs, circumstances, preferences and the supports most urgently needed. Strategies are developed in collaboration with the client and/or family for achieving the agreed goals. The wellbeing nurse discusses assessment results with the client and/or family members if appropriate and provides them with information on supports and services that would help them make an informed decision and meet their agreed upon goals. If a referral to service/s is required, the wellbeing nurse discusses referral options with client and/or family members and obtains the appropriate consent to refer the client to the service/s.
The wellbeing nurse collaborates with the school learning and support and wellbeing team, health services and other agencies to contribute to case planning and communicates and coordinates referrals between services/organisations for the client, as required.
The wellbeing nurse coordinates the client’s and/or their family members' access to appropriate early and therapeutic intervention, assessments and referral to other services and programs. They support the client and/or family members to navigate and engage with the service/s and programs as required until they can navigate health services and programs by themselves. This may include assisting the client and/or family to schedule appointments with services, attending appointments with the client and family, and assisting them to understand the health information.
The wellbeing nurse manages and tracks referrals and outcomes with the client and/or family and services/organisations involved in the client’s care via email, phone call and/or meetings as required. The wellbeing nurse can make additional referrals as required if other supports and services are needed.
