Presentation on theme: "Other Chronic Care Programs in the Tweed Valley Community Health Centers."— Presentation transcript:
Other Chronic Care Programs in the Tweed Valley Community Health Centers
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 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
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
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: 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 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 : 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
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 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
How to refer clients 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
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
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
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.
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 feedback phone