1. Gold Coast Hospital and Health Service
Flinders Care Plan
Gold Coast Hospital and Health Service
Rose Costa Coordinator
Chronic Disease Management
Gold Coast Hospital & Health Service
Judy Murrells Respiratory 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
Clinical Nurse Consultants Respiratory
Clinical Nurses Respiratory Enrolled Nurse
Pharmacists
Physiotherapists
Exercise Physiologist
Social Workers
Psychologist
Dietitians
Podiatrists
Occupational Therapists
Speech Pathologist
Support staff:
Allied Health Assistants
Partner with Aboriginal & Torres Strait Islander Health Workers

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

7. 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