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Yudi – 48 Hour Follow Up: Aboriginal Chronic Disease Care Coordination

Yudi means ‘to escort or to see home’. 

The Yudi Service is for Aboriginal people who have a chronic medical condition. A chronic medical condition is an illness that can be managed with medical treatment but cannot be cured, such as asthma, cardiovascular disease and diabetes.
 

rpavirtual Yudi 48 Hour Follow Up Aboriginal
SydneyConnect Image: Yudi Aboriginal Health Workers

What to expect

Prior to your hospital discharge 

An Aboriginal Health Worker will come to the hospital while you are still there, introduce themselves to you to inform you about the program and what to expect.  

Within 48 hours of your discharge

To help support your transition to home, within two working days of your discharge from hospital an Aboriginal Health Worker will call you to: 

  • Check to see how you are feeling and managing at home since your discharge from hospital 
  • Ask you if you have any questions about your discharge plan 
  • If needed, arrange support from a pharmacist to help you understand your medications
  • Ask if you have any follow-up appointments with specialist doctors
  • Check if you have been able to fill your discharge medication prescriptions.  
  • Check if your General Practitioner (GP) is registered with Closing the Gap to make sure you get discounts on your medical scripts 
  • Check if you have enough family support at home or in the community  

The team can help you contact your General Practitioner (GP or local doctor) or specialist team. They can also refer you to other services such as Planned Care for Better Health, the Chronic Disease Aboriginal Program. 

How to access

Referrals are accepted from Sydney Local Health District hospitals. If you are Aboriginal, have a chronic condition, are over 15 years old and are a patient in a Sydney Local Health District Hospital the 48 hour follow up team will refer you to the program. See the Information for Professionals page.