Complex Chronic Disease Team (CCDT)

The complex needs service focusses on clients whose care needs require greater than usual levels of health care management due to a multitude of interacting physical, psychological and social factors. The aim of this service is to identify and address factors that limit client’s wellbeing and quality of life through targeted interventions, self-management capacity building and facilitating access to appropriate health and support services.

Clients referred to this service are those that experience;

• High risk of deterioration due to difficulty managing their chronic health conditions
• Poorly coordinated care due to a lack of integration between multiple specialists and services
• A pattern of frequent emergency presentations and hospital admissions
• Vulnerability due to poor psychosocial support and with complex socioeconomic needs

This service operates in clinics located at North Lakes Health Precinct and Nundah Community Health Centre, in client’s home via a home visiting service or telehealth. Clients referred to this service can expect a comprehensive initial and ongoing assessment to identify their care needs and the development of an individualised care plan. The multidisciplinary team will work with the client and their support network to meet the goals and actions identified in the care plan and assist with coordinating a plan for long term support.

General Physician consultation services are provided at Nundah and North Lakes clinics for clients requiring a coordinated management approach due to multiple interacting co-morbidities and polypharmacy.

Geriatrician consultation services are provided at Nundah and North Lakes clinics for clients requiring a comprehensive geriatric assessment and a coordinated management plan to address issues such as cognitive impairment, falls, incontinence and polypharmacy.

Clients who reside in a Residential Aged Care Facility or those with established comprehensive care packages (e.g. NDIS, level 3 or 4 Home Care Packages) with access to required multidisciplinary supports are not suitable for referral to the service*.
*Referrals for multidisciplinary healthcare needs not provided by the comprehensive care package may be considered for the Complex Needs Service and/or Specialist Medical Clinics.

Other exclusion criteria include clients requiring;

• single discipline intervention – we recommend clients discuss accessing Medicare rebates for certain allied health services with their GP
• maintenance therapy
• ongoing intensive rehabilitation interventions
• immediate intervention or acute care management
• a seven day a week service
• primary care needs relate to drug and alcohol dependency or Mental Health issues
• palliation

* home visits are limited and will not be provided to high risk clients or environments

The cardiac rehabilitation service provides an integrated education and exercise program for clients following a recent (within 6 months) cardiac event including NSTEMI or STEMI, PCI, Coronary Artery Bypass Grafting, Cardiac Valve Surgery or clients who have medically stable Heart Failure.

This program is conducted over 6 weeks, it includes the following

• Group exercise program- twice weekly gym sessions for 6 weeks
• Education program – one session per week on varying topics related to health, diet and fitness delivered online or centre based
• Service available at North Lakes Health Precinct, Caboolture King Street, Chermside Community Health Centre or Nundah Community Health Centre
• Suitable clients will be assessed for home based virtual care delivery

Referrals are not accepted for atrial fibrillation, permanent pacemaker or angina as the primary cardiac condition. Consultation with the client’s GP to develop a cardiovascular Chronic Disease Management Plan is recommended.

The pulmonary rehabilitation service provides an integrated education and exercise program for clients with a pulmonary diagnosis who are medically stable and would benefit from group-based exercise sessions. Client groups include COPD, Bronchiectasis, Interstitial lung disease, Pulmonary Fibrosis or pre transplant.

This program is conducted over 8 weeks, it includes the following

• Group exercise session- twice weekly gym sessions for 8 weeks
• Education program- one session per week on varying topics related to health, diet and fitness delivered online or centre based
• Service available at North Lakes Health Precinct and Caboolture King Street
• Suitable clients will be assessed for home based virtual care delivery

Referral are not accepted for clients who have complete a Pulmonary Rehabilitation program in the past 2 years or post-acute general respiratory illness (e.g. pneumonia).