Other Chronic Care Programs in the Tweed Valley Community Health Centers

1. Other Chronic Care Programs in the Tweed Valley Community Health Centers

2. 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

3. 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

4. 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

5. 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 referral GP communication Early detection; BP check, urine dipstick for protein, blood test eGFR Letter by renal physician to GP. We would send a return letter/email if referred directly from GP

6. 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

7. 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

8. 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.

9. 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

10. 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

11. 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

12. 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 55067652 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

13. Respiratory • Pulmonary rehabilitation • Tweed • Murwillumbah • Byron • Respiratory clinic - Kingscliff • Home respiratory service - new (Byron), • Pottsville cardiac/resp clinic (health one) - planning phase

14. 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

15. Types of service Pulmonary 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

16. 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 – Programexit 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

17. 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

18. CHEGS Inc Stepping On • Free 7 week falls prevention course • Strengthening and balance • Suitable for – Over 65 Living at home Independently mobile Referrals email mary.ward@ncahs.health.nsw.gov.au Or call Mary on 02 66207523

19. 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.

20. 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.

21. 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.

22. 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 feedback Kerrie.Keyte@ncahs.health.nsw.gov.au phone - 02 6670 9401