Complex Care (Nurse Navigation / Complex Discharge Service)Community
Urgent Advice
- Referrals to Complex Care can be discussed Monday to Friday,
0800 -1630 on 1300 004 242. - For urgent advice outside business hours, please contact the consultant through switchboard 1300 744 284 or our GP Only Enquiry Line 5687 0003.
Are you referring to the right service?
- The Complex Care service provides care to clients with complexities where it is identified that navigation principles will improve health outcomes and prevent future avoidable presentations to the hospital.
- Clients have complex needs who are living in the community and are known to the health service; where there exists a risk of presentation to hospital due to bio-psychosocial, clinical and other complexities and/or an associated risk of sustainability of current services provided in the community as a result of these complexities.
- Complex Care Nurse Navigators operate in line with Office of the Chief Nursing and Midwifery Officer (OCNMO) program guidelines in:
- Creating Partnerships – NGOs, GPs, specialists and other OPD
- Facilitating Service improvement – streamlining appointments, linkage with primary health
- Care coordination – facilitating case conference, linkage with clinicians or establishing shared management plans, advocating for alternative pathways
- Improving Patient Outcomes – personalised, goal-based, counselling, establish ongoing services or self-management
- The aim is to provide sustainable and high value health care by decreasing health service burden, improving population and individual health with a wellness and ablement approach to health needs.
- The Complex Discharge Service is a multi-disciplinary team delivering specialist allied health navigation to support high-value health care. This may mean reducing the risk of avoidable hospital presentations and assisting to sustain safety of patients in transition between hospital and community within their own home via:
- Collaboration with GPs and NGOs for service linkage and navigation.
- Assisting with developing shared management plans for hospital avoidance and alternatives.
- Providing specialist allied health psychosocial and functional assessments and referrals when needed to reduce the risk of avoidable hospital presentations and support early safe discharge.
- Linkage to ongoing services by assisting patients to access NDIS, My Aged Care, QCAT etc to support future high value health service utilisation.
- As such, CDS provides specialist consultation, referral, support and advice for inpatient treating teams, GPs and other health agencies.
- These patients have psychosocial, clinical or other vulnerabilities that exist outside of the hospital setting and risk the effective implementation of established plans for discharge or at imminent risk of avoidable hospital admission.
Important referral information
- Medical governance will be with the patient’s GP
- Ongoing communication with the GP will occur throughout the duration of the service
- Upon discharge from Complex Care, an updated summary will be provided to the GP outlining the intervention provided, recommendations for ongoing care, as well as onward referral.
Out of Scope Services
The following conditions are out of scope for this service:
- A private patient or patient previously unknown to GCHHS
- An inpatient being managed by a treating MDT; or a community member with sufficient supports and services in place
- A person who has sufficient referrals or services in place from other areas
- Already known to another nurse navigation or specialist case management service
Out of Catchment
Gold Coast Health is responsible for providing public health services to the people who reside within its boundaries. Special consideration is made for patients requiring tertiary services or for services that are not provided by their local hospital and health service district. If your patient lives outside the Gold Coast Health catchment area and you wish to refer them to one of our services, please indicate relevant medical or social information that will assist with the processing of your referral.
Notes
Please note that where appropriate and where available, the referral may be streamed to an associated public allied health and/or nursing service. Access to some specific services may include initial assessment and management by associated allied health and/or nursing, which may either facilitate or negate the need to see the public medical specialist.
- A change in patient circumstance (such as condition deteriorating or becoming pregnant) may affect the urgency categorisation and should be communicated as soon as possible.
- Please indicate in the referral if the patient is unable to access mandatory tests or investigations as they incur a cost or are unavailable locally.
- If your patient consents to telehealth, please indicate in the body of the referral.
Patient Must Bring
- Medicare card
- Any concession cards (e.g. Pension, Health Care, DVA, PBS Safety Net, ADF, etc.)
- Current medication list
- Reading glasses, hearing and mobility aids
Send Referrals To
Smart Referrals
Preferred Method
About Smart Referrals
Secure Web Transfer
Send to: Gold Coast Health Service District
Internal Referrals
Complex Care (E-Blueslips)
Fax
Post
Booking and Referral Centre
Gold Coast University Hospital
1 Hospital Boulevard
Southport QLD 4215
Enquiries
Service Availability
Facilities
If you would like to send a named referral, please address it to the specialist listed above, who will allocate a suitably qualified specialist to see the patient. Alternatively, you can view a full list of our specialists.