Presentation on theme: "Other Chronic Care Programs in the Tweed Valley"— Presentation transcript:
1 Other Chronic Care Programs in the Tweed Valley Community Health Centers
2 Diabetes services Diabetes Educator and Dietitian Tweed Community HealthKingscliff Community HealthBugalwena GP surgeryMuwillumbah Community HealthDeadly Living Group - Aboriginal specificFor patients with chronic disease and at those at risk of chronic diseaseDiabetes 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– GroupsDiabetes support group MurwillumbahDiabetes Support group PottsvilleDiabetes Support Group Tweed Heads
5 Renal outreach services How to refer clientsDirectly to renal outreach service at Tweed Hospital - Claire McLaren Ph OR Renal unit fax –GP or nephrologist referralGP communicationEarly detection; BP check, urine dipstick for protein, blood test eGFRLetter 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 phHeart Failure serviceTweed –Byron phNot 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 settingsThe Program focuses on education, exercise and self management strategies including:-daily weighing,salt and fluid restriction,managing symptoms,Medication compliance and side effectsrisk factors & depressionExercising for healthHeart failure action plan & diuretic titration in consultation with the GP
8 Types of HF serviceUsing a multi-disciplinary approach the Program includes education from a Heart Failure CNS, Social Worker, Dietician, Occupational Therapist, Pharmacist and PhysiotherapistPatients attend for average of 8 – 10 weeks.Wednesdays from 10:00 – 12:00For diagnosed HF patients with breathlessness on minimal – ordinary exertion (NYHA 1-111)Home visiting - for those patients unable to attend.
9 How to refer clientsReferral Form withExercise Clearance from GP or CardiologistCopy of the GPMP and other results e.g. ECHOFax to: Heart Failure Nurse, Francesca Leaton on fax number:GP CommunicationGP letter pre and post service deliveryEntry and exit clinical improvement informationOngoing issues identifiedReferrals made during the course of the program
10 Tweed Cardiac Rehabilitation Across inpatient and outpatient settingsFocus on education, exercise and self managementRisk factor management / behaviour changeManaging symptoms, positive lifestyle supportTaking medications in consultation with the GPExercisingDepression screening [PHQ9]Chest pain action plan
11 Types of serviceMulti-disciplinary exercise and education groups (6 weeks)Cardiac Assessment Nurse, clinical nurse educator, physiotherapist, pharmacist, dietician, social worker, occupational therapistExercise: Tuesday & Thursday Education: Thursdays 10am-12For Acute Coronary Syndrome, Angina, post valve replacement, CABG, arrhythmias, at risk patients
12 How to refer clientsReferral Form withExercise Clearance from GP or CardiologistCopy of the GPMP and other results eg ECHOFax to: Kellie Thompson /Sally ChambersPhone : Fax:GP CommunicationGP letter pre and post service deliveryEntry and exit clinical improvement informationOngoing issues identifiedReferrals made during the course of the program
14 Respiratory Tweed Respiratory service Across inpatient and outpatient settingsFocus on Providing respiratory disease education, exercise and improving quality of life;utilising breathing techniques for breathlessnessIncreasing walking distanceGiving clients techniques in self management including medication regime/ inhaler techniques and action plans
15 Types of service Pulmonary rehabilitation Multidisciplinary group education and exercise8 week program - Tuesdays & Thursdays (10-12)GP referral required with copies of previous spirometry reports and action plans.Kingscliff respiratory clinicsClinical Nurse Specialist consultationSpirometryBreathing 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 contactGP CommunicationPulmonary 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 NNSWLHD45 exercise classes per week across the $5 per classGentle exercise, Better Beat, Stretch & Strengthen, Qigong/Tai ChiRegistered & insured Fitness Instructors
18 CHEGS Inc Stepping On Free 7 week falls prevention course Strengthening and balanceSuitable for –Over 65Living at homeIndependently mobile ReferralsOr call Mary on
19 Project NNSWLHD- Single Point of Contact to Community Health – Why? Funded by the Chronic Disease Management ProgramFeedback from GP’s, the community and other services indicate that navigating our services can often be difficultCommunity Health offers a broad range of services, many of which the GP’s are unaware ofOur receptionists are challenged withKnowing all the services that are available andDifferent access criteria /processes for each one.
20 Single Point of Contact - A BETTER WAY LHD & Medicare local partnershipNew 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 achieveCommences end Nov 2012Mail out to all practicesBridge gaps between our servicesImprove our communications between the GP Practices, Medicare Local and Community HealthTo do this effectively we need your feedbackphone