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

2. Diabetes services Diabetes Educator and Dietitian
Tweed Community Health
Kingscliff Community Health
Bugalwena GP surgery
Muwillumbah Community Health
Deadly Living Group - Aboriginal specific
For patients with chronic disease and at those at risk of chronic disease
Diabetes CNC Tweed/Murwillumbah historically sat at murbah but covered Tweed Valley 2 x PT CNS Tweed CH & Hospital Pottsville Group is diabetes support group not run by health. Tweed has regular groups Murbah group currently on hold due to CNC vacancy.

3. Diabetes services One on one diabetes educator in Byron Shire
Diabetes and Dietitian Support and education– Groups
Diabetes support group Murwillumbah
Diabetes Support group Pottsville
Diabetes Support Group Tweed Heads

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 OR Renal unit fax –
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/ if referred directly from GP

6. Cardiac Cardiac Rehabilitation Tweed – 07 55067211
Murwillumbah –
Byron shire ph
Heart Failure service
Tweed –
Byron ph
Not sure how much the GPs are aware of Health One The old division and Dr Chin’s practice has been involved in planning.

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:
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 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 : Fax:
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 Respiratory clinic - Kingscliff
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 GP Communication
Respiratory Clinic – GP referral with a health summary please Kingscliff fax :
Pulmonary Rehab – GP referral with a health summary please Tweed fax:
Allison Eastman phone contact
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

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 $5 per class
Gentle exercise, Better Beat, Stretch & Strengthen, Qigong/Tai Chi
Registered & insured Fitness Instructors

18. CHEGS Inc Stepping On Free 7 week falls prevention course
Strengthening and balance
Suitable for –
Over 65
Living at home
Independently mobile Referrals
Or call Mary on

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. To do this effectively we need your feedback
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
phone