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

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Presentation on theme: "Other Chronic Care Programs in the Tweed Valley Community Health Centers."— Presentation transcript:

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 – 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 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.aumary.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 GPs, 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 GPs 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


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