1 / 7

Comprehensive Chronic Disease Care Plan

Accessible and concise care plan for multi-morbid chronic care needs, with shared assessment and consultation across services.

brentd
Download Presentation

Comprehensive Chronic Disease Care Plan

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Flinders Care Plan Gold Coast Hospital and Health Service Rose CostaCoordinator Chronic Disease Management Gold Coast Hospital & Health Service Judy MurrellsRespiratory CNC Chronic Disease Management Gold Coast Hospital & Health Service

  2. Caring for the multi-morbid chronic care needs • Capacity for consultation across services to meet care needs. • Shared initial chronic disease assessment and care plan across services South: Robina Health Precinct North: Helensvale Community Health Centre Monday to Friday 8.00am-5.00pm

  3. Chronic Disease & Post Acute Programs • Chronic Disease Wellness Program • Heart Failure Service • Respiratory Service • Diabetes Service • Chronic Kidney Disease Service • Partnership with Mungulli and Heart Health (Aboriginal & Torres Strait Islander chronic disease) • Cardiac Rehabilitation • Post Acute Program • Multiple Sclerosis Fitness • Community Referrals • Falls and Balance Clinic

  4. The multidisciplinary team Direct appointment into Respiratory Outpatient Clinics if required

  5. Care Plan Accessible + Concise within Ax • Included in suite of clinical forms • Accessible by link to staff within the chronic disease service • A user friendly care plan • Saved electronically to CD program • Printed and signed by client & clinician

  6. Post program outcomes recorded • Update end of programs • Conversation with client • Client Goal statement gained/partially gained? re-score • Client Problem statement reduced? Re-score • Copy for client/carer • Copy for GP as part of transfer of care

More Related