Other Chronic Care Programs

in the Tweed Valley

Community Health Centers

Diabetes services• Diabetes Educator and Dietitian – Tweed Community Health 0755067540– Kingscliff Community Health 02 66749500– Bugalwena GP surgery 07 55131322–Muwillumbah Community Health 02 66709400

• Deadly Living Group - Aboriginal specific 0755131322– For patients with chronic disease and at those at risk of

chronic disease

Diabetes services

• One on one diabetes educator in Byron Shire

• Diabetes and Dietitian Support and education– Groups– Diabetes support group Murwillumbah 0266709400– Diabetes Support group Pottsville 0266749500– Diabetes Support Group Tweed Heads 0755067540

Renal outreach services

Tweed Hospital Renal Outreach Service - Clinical Nurse Specialists available for;

•Chronic kidney disease education•Predialysis education – Renal replacement options (Haemodialysis, peritoneal dialysis, conservative management & transplant)•Home dialysis patient management

Renal outreach services How to refer clients• Directly to renal outreach service at Tweed Hospital - Claire McLaren Ph 07 5506 7215 OR Renal unit 07 55067220 fax – 07 55067214• GP or nephrologist referralGP communication Early detection; BP check, urine dipstick for protein, blood test eGFRLetter by renal physician to GP. We would send a return letter/email if referred directly from GP

Cardiac Cardiac Rehabilitation –Tweed – 07 55067211–Murwillumbah – 02 66720102 –Byron shire - 041456683 ph 02 66856254

Heart Failure service –Tweed – 07 55067818–Murwillumbah – 02 66720102 –Byron - 041456683 ph 02 66856254

The Tweed Heart Failure Program• Across inpatient & community settings• The Program focuses on education, exercise

and self management strategies including:-– daily weighing, – salt and fluid restriction, – managing symptoms, –Medication compliance and side effects– risk factors & depression – Exercising for health – Heart failure action plan & diuretic titration in

consultation with the GP

Types of HF service

• Using a multi-disciplinary approach the Program includes education from a Heart Failure CNS, Social Worker, Dietician, Occupational Therapist, Pharmacist and Physiotherapist– Patients attend for average of 8 – 10 weeks.– Wednesdays from 10:00 – 12:00– For diagnosed HF patients with breathlessness on

minimal – ordinary exertion (NYHA 1-111)• Home visiting - for those patients unable to attend.

How to refer clients

• Referral Form with– Exercise Clearance from GP or Cardiologist – Copy of the GPMP and other results e.g. ECHO

• Fax to: Heart Failure Nurse, Francesca Leaton on fax number: 0755067844

GP Communication• GP letter pre and post service delivery • Entry and exit clinical improvement information• Ongoing issues identified • Referrals made during the course of the program

Tweed Cardiac Rehabilitation

• Across inpatient and outpatient settings• Focus on education, exercise and self

management– Risk factor management / behaviour change–Managing symptoms, positive lifestyle support– Taking medications in consultation with the GP– Exercising – Depression screening [PHQ9]– Chest pain action plan

Types of service

• Multi-disciplinary exercise and education groups (6 weeks)– Cardiac Assessment Nurse, clinical nurse educator,

physiotherapist, pharmacist, dietician, social worker, occupational therapist

– Exercise: Tuesday & Thursday 0830-0930 Education: Thursdays 10am-12

– For Acute Coronary Syndrome, Angina, post valve replacement, CABG, arrhythmias, at risk patients

How to refer clients

• Referral Form with– Exercise Clearance from GP or Cardiologist – Copy of the GPMP and other results eg ECHO

• Fax to: Kellie Thompson /Sally Chambers • Phone : 07 55067211 Fax:- 07 55067652GP Communication• GP letter pre and post service delivery • Entry and exit clinical improvement information• Ongoing issues identified • Referrals made during the course of the program

Respiratory

• Pulmonary rehabilitation – Tweed–Murwillumbah– Byron

• Respiratory clinic - Kingscliff• Home respiratory service - new (Byron), • Pottsville cardiac/resp clinic (health one) -

planning phase

Respiratory Tweed Respiratory service•Across inpatient and outpatient settings •Focus on Providing respiratory disease education, exercise and improving quality of life;-utilising breathing techniques for breathlessness -Increasing walking distance -Giving clients techniques in self management including medication regime/ inhaler techniques and action plans

Types of servicePulmonary rehabilitation– Multidisciplinary group education and exercise– 8 week program - Tuesdays & Thursdays (10-12)– GP referral required with copies of previous spirometry

reports and action plans.

Kingscliff respiratory clinics• Clinical Nurse Specialist consultation• Spirometry • Breathing techniques, medication and inhaler usage,

action plans. • Communication with respiratory specialist & GP

How to refer clients• Respiratory Clinic – GP referral with a health summary please

Kingscliff fax : 02 66749599• Pulmonary Rehab – GP referral with a health summary please

Tweed fax: 07 55067844• Allison Eastman phone contact 07 5506 7851• Allison.eastman@ncahs.heatlh.nsw.gov.au

GP Communication • Pulmonary Rehab – Program exit letter to GP with

assessment results and clinical improvement information e.g. 6mwt, lung function.

• Clinic – GP letter with recommendations and clinic assessment with individual plans for each client

CHEGS Inc. (Community Health Education Groups)

Maintenance Groups • Self-funded NGO – Manager Mary Ward,

position funded by NNSWLHD• 45 exercise classes per week across the LHD @

$5 per class• Gentle exercise, Better Beat, Stretch &

Strengthen, Qigong/Tai Chi• Registered & insured Fitness Instructors• www.chegs.org.au

CHEGS IncStepping On•Free 7 week falls prevention course•Strengthening and balance •Suitable for –

Over 65 Living at homeIndependently mobile

Referrals email mary.ward@ncahs.health.nsw.gov.auOr call Mary on 02 66207523

Project NNSWLHD- Single Point of Contact to Community Health – Why?

Funded by the Chronic Disease Management Program

Feedback from GP’s, the community and other services indicate that navigating our services can often be difficult

Community Health offers a broad range of services, many of which the GP’s are unaware of

Our receptionists are challenged with Knowing all the services that are available and Different access criteria /processes for each one.

Single Point of Contact - A BETTER WAY

LHD & Medicare local partnership

New 1300 number for easier phone access, creating an Integrated regional presence of our services.

A new phone menu with options so that your call is directed to the centre that your require.

Installed a new “Interactive client” computer based telephone system to assist with improving our call flows and address inefficiencies.

Single Point of Contact - A BETTER WAY Trial is underway - new referral form can be

uploaded into your clinical software.

Tweed/Byron Community and Allied Health Services information to assist with referrals. updated every six months. Sent electronically to your practice.

Gain feedback and make necessary changes to improve the referral process between your practice and community health.

What we want to achieve

• Commences end Nov 2012• Mail out to all practices• Bridge gaps between our services• Improve our communications between the GP

Practices, Medicare Local and Community Health

To do this effectively we need your feedbackKerrie.Keyte@ncahs.health.nsw.gov.au

phone - 02 6670 9401