Table 1 Eligibility criteria for the North Coast connecting care program

Inclusion characteristics

Usual residential address within North Coast Area Health Service, and

Aged over 65 at admission, and

One or more diagnoses of:

· Chronic Obstructive Pulmonary Disease (COPD) (ICD10: J41 to J44)

· Diabetes (ICD10: E10 to E15)

· Hypertension (ICD10: I10, I11.9)

· Congestive heart failure (CHF) (ICD10: I50, I11.0, J81)

· Coronary artery disease (ICD10: I20 to I25)

At least one unplanned acute admission in any 12 month period between July 2008 and Dec 2009 with one of the above five diseases as the principal diagnosis and a total of 3 or more unplanned acute hospital admissions in the same 12 month period with one of the five diseases as either the principal diagnosis or an additional diagnosis

Exclusion characteristics

In receipt of palliative care

In a residential aged care facility