Complex Chronic Disease

Complex Chronic disease referral form

Complex Needs Service (Consultation and Care Planning)

Complex clients have care needs that require greater than usual levels of health care management due to a multitude of interacting biological, psychological and social factors. They often require input from multiple specialist providers, prescription of multiple medications and management of one condition conflicting with the management of another.

We can help by:

• Providing a multidisciplinary assessment and consultation to develop a co-ordinated care plan that helps meet health and well-being goals set between your client and our service
• Integrating multiple care plans to provide a comprehensive centralised care plan.
• Work in partnership with the client, their general practitioner and other required health services to ensure the co-ordinated delivery of their individualised care plan

Please note: As this is a specialist multidisciplinary service, referrals received for clients who only require single discipline intervention, maintenance therapy or routine follow-up will be forwarded on to an appropriate service provider in liaison with the client and their general practitioner.

Services are available at North Lakes and Nundah Health Centres (clients may be eligible for home visits depending on assessed need).

Disease specific rehabilitation programs

Evidence based education and exercise disease specific management programs:

Cardiac and heart failure rehabilitation

For clients with a recent (within 6 months) cardiac event including MI, stent, cardiac bypass/valve surgery or who have medically stable heart failure.

• Education program – 8 weekly sessions or option of Fast Track (1 day session)
• Group exercise sessions- twice weekly for 6 weeks
• Service available at North Lakes Health Precinct, Redcliffe Hospital, Caboolture Hospital or Chermside Community Health

* We are excited to announce mobile delivery of our cardiac rehabilitation program (MoTER) available through the use of your client’s own phone.

Pulmonary rehabilitation

For clients with a pulmonary diagnosis who are medically stable and would benefit from group based exercise sessions.

• 8 week program- twice weekly exercise group and weekly education sessions
• Service available at North Lakes Health Precinct