Chronic disease management in Southern NSW

Our service can assess your needs and provide specific information to help you manage your heart health. Your nurse will work with your GP or doctor and medical specialist to ensure your care is coordinated and meets your needs.

Our staff can provide you with specific and practical information to help you manage your heart condition and speed up your recovery including:

• individual assessment and regular reviews
• daily management activities including driving and return to work
• low to moderate physical activity guidelines and exercise groups
• education about heart disease and emotional support
• managing your medications
• support to help you work on aspects of your heart health such as smoking cessation, healthy eating and activity levels.

For information on your closest Heart (Cardiac) Rehabilitation service please contact the Community Health Central Intake Service on 1800 999 880.

A local Diabetes Educator and Dietitian will individualise their education program specific for your needs. They will work with you to achieve best self-care management through the following steps to success:

• healthy eating
• being active
• monitoring your sugar levels
• taking medication
• problem solving
• healthy approach to coping with diabetes
• reducing risk factors that impact your health.

To make an appointment with a local Diabetes Educator or a Dietitian please contact the Community Health Central Intake Service on 1800 999 880.

Services are provided for all people with diabetes including:

• people with pre-diabetes symptoms
• those newly diagnosed with diabetes
• diabetes in pregnancy
• all age groups impacted by diabetes.

Specialist Clinics are also available for more complex conditions. Clinics incorporate advanced assessment and treatment planning.

The Nurse Practitioner Diabetes service is a new mobile diabetes service incorporating advanced assessment and treatment planning. Based at the Queanbeyan Health Service, it provides face-to-face visits at Community Health Centres located within the Southern NSW LHD on a rotating schedule every three months.

Services include:

• comprehensive assessment, identification and prioritising of clinical issues
• planning, implementation and evaluating treatment strategies
• medication management
• assistance with continuum of care and integration of services across sites and disciplines
• case management and consultation of patients with other diabetes team members
• identification of patients requiring referral to diabetes medical specialist clinics.

Criteria for referral include:

• patients over 15 years who have an identified diabetes related health care concern that is not able to be managed by standard community service
• patients who are at risk of presenting to the emergency department or being admitted/re-admitted, and who would benefit from a management plan as part of hospital avoidance.

How to refer

Community referrals can be made by GPs through Southern NSW LHD Community Health Central Intake Service on 1800 999 880 or by emailing SNSWLHD-CommunityIntake@health.nsw.gov.au. 

A referral form and details can be accessed at ACT and SNSW HealthPathways, search for Routine Diabetes Team Referrals and select SNSW.

Criteria list for referral 

Referral inclusion criteria:

• patients with type 1 diabetes, LADA, type 2 diabetes
• HbA1c greater than 8.5% (greater than 69mmol/mol) with or without hospital presentation/admission in the past 12 months)
• blood glucose levels consistently elevated
• eGFR greater than 45mL/min/1.73m2
• type 2 diabetes requiring insulin or GLP-1 initiation or titration
• newly diagnosed type 2 diabetes not stabilised within 3 months
• prescribed corticosteroids (prednisolone and dexamethasone) regardless of HbA1c
• prescribing of all glucose lowering medicines and glucagon (except where CTO listed)
• prescribing of all blood pressure lowering agents (except where CTO listed)
• prescribing of all lipid modifying agents (except where CTO listed)
• dose alteration or cessation of above medicines.

Referral exclusion criteria:

• patients aged 15 years and under
• women with pre-gestational diabetes and pregnancy
• women with gestational diabetes mellitus (GDM) requiring insulin prior to 20 weeks gestation
• patients suspected/diagnosis with pancreatic cancer
• patients with stage 3b, 4 or 5 chronic kidney disease (Kidney Health Australia)
• patients with class III or IV heart failure (NYHA grading system)
• unstable or life threatening medical conditions (non-diabetes)
• patients in whom diabetes management is not the current focus of treatment.

We provide information, support and treatment for individuals (and their families) affected by kidney disease.

Once you have been referred to our service the renal team will work with you, your family and your doctor (GP) to manage your kidney disease, providing support and care along the way.

Renal services we provide

Canberra Hospital Renal Services

The Canberra Hospital Renal Service provides comprehensive clinical care, including dialysis and post-transplant care for patients with kidney diseases, inclusive of community and allied health services.

• outpatient services
  • high blood pressure management
  • chronic kidney disease management
• general nephrology
• inpatient services
• pre and post kidney transplant care and management
• haemodialysis: acute and community
• home based dialysis therapies (peritoneal dialysis and home haemodialysis)
• home dialysis patient training
• nocturnal haemodialysis patient training
• renal supportive care and symptom management
• access surgery for dialysis provided by vascular team at Canberra Hospital.

Renal Services in Southern NSW

• bulk billed renal clinics
• chronic kidney disease (ckd) management  
• ckd treatment options education and support
• dialysis including home based treatments
• renal supportive care and symptom management  

Please note: The renal service in Southern NSW LHD does not provide services for children under 16 years old. Please speak directly with your doctor or GP if your child requires renal services.

Management and support for adults with kidney disease is available across the Southern NSW Local Health District. Your doctor (GP) needs to refer you to renal doctors (specialists) at Canberra Hospital.

Once you have been referred to our service the renal team will work with you, your family and your doctor (GP) to manage your kidney disease, providing support and care along the way.

We are here to help you manage your kidney disease and we provide information, support and treatment for individuals (and their families) affected by kidney disease.

Renal Services we provide

In Southern NSW, bulk billed renal clinics are held at South East Regional Hospital Bega, Goulburn, Moruya, Batemans Bay, Queanbeyan dialysis unit and Cooma Community Health.

Clinics include:

• visiting renal specialist doctors from Canberra Hospital 
• local support by a Renal Outreach Clinical Nurse Specialist.
   

Renal Outreach Support services include:

• chronic kidney disease (ckd) Management
• ckd treatment options education and support
• managed locally by a Renal Nurse
• support from a dietitian and social worker.

Home dialysis management consists of:   

• peritoneal dialysis and Home Haemodialysis
• managed by the Canberra Hospital Renal Home Therapies Unit
• supported locally by a Renal Outreach nurse
• home dialysis training available at some sites in Southern NSW LHD.

Canberra Hospital Renal Home Therapies Unit provides home dialysis training, management and support.

Queanbeyan, Moruya, Bega, Goulburn and Cooma dialysis units:  

• provide in-centre haemodialysis treatments, if this is the most suitable treatment for you
• staffed by renal nurses
• support and promote self-management.

Renal Supportive care

If you choose not to have dialysis and/or require symptom management, care and support will be provided by the renal service, allied health and renal supportive care teams (locally where available).