Aboriginal and Torres Strait Islander Chronic Disease Nurse Navigation
Adult

Nurse Navigator - Aboriginal and Torres Strait Islander Service

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Emergency Referrals

Useful Management Information

Not providing a service – Navigation of services

This service can be accessed by Aboriginal and Torres Strait Islander clients where it is identified that navigation principles will improve health outcomes and prevent future avoidable presentations to the hospital.
The Aboriginal and Torres Strait Islander Chronic Disease / Complex care navigation offers 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.
Aboriginal and Torres Strait Islander Nurse Navigators operate in line with First Nations Health Equity Strategy and The 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 Aboriginal and Torres Strait Islander Chronic Disease / Complex care navigation supports 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.
Linkage to ongoing services by assisting clients to access Aboriginal and Torres Strait islander community services, My Aged Care, to support future high value health service utilisation.

Minimum Referral Criteria

Does your patient meet the minimum referral criteria?

Category 1 (appointment within 30 calendar days)	First Nations patients who are at high risk of hospital re-presentation
Category 2 (appointment within 90 calendar days)	First Nations patients who are at moderate risk -low risk of hospital re-presentation
Category 3 (appointment within 365 calendar days)	No category 3 criteria
If your patient does not meet the minimum referral criteria Assessment and management information may be found on a range of conditions at HealthPathways If the patient does not meet the criteria for referral but the referring practitioner believes the patient requires specialist review, a clinical override may be requested: Please explain why (e.g. warning signs or symptoms, clinical modifiers, uncertain about diagnosis, etc.) Please note that your referral may not be accepted or may be redirected to another service

Standard Referral Information

Reason for request

To establish a diagnosis
For treatment or intervention
For advice and management
For specialist to take over management
Reassurance for GP/second opinion
For a specified test/investigation the GP can't order, or the patient can't afford or access
Reassurance for the patient/family
For other reason (e.g. rapidly accelerating disease progression)
Clinical judgement indicates a referral for specialist review is necessary

Relevant clinical information about the condition

Presenting symptoms (evolution and duration)
Physical findings
Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
All conservative options that have been pursued unsuccessfully prior to referral
Body mass index (BMI)
Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
Any special care requirements where relevant (e.g tracheostomy in place, oxygen required)
Current medications and dosages
Drug allergies
Alcohol, tobacco and other drugs use

Patient's Demographic Details

Full name (including aliases)
Date and country of birth
Residential and postal address including whether patient resides at an aged care facility
Telephone contact number/s – home, mobile and alternative
Medicare number (where eligible)
Name of the parent or caregiver (if appropriate)
Name of delegate and contact details (Department of Corrective Services)
Preferred language and interpreter requirements
Identifies as Aboriginal and/or Torres Strait Islander
Any special needs, access requirements and/or disability relevant to the referral

Referring Practitioner Details

Full name
Full address
Contact details – telephone, fax, email
Provider number
Date of referral
Signature
Nominated general practitioner’s details (if known), if the nominated general practitioner is different from the referring practitioner

Other relevant information

Willingness to have surgery (where surgery is a likely intervention)
Choice to be treated as a public or private patient
Compensable status (e.g. DVA, Work Cover, Motor Vehicle Insurance, etc.)

Essential Referral Information

Indigenous Status information eg. Aboriginal, Torres Strait Islander, Both Aboriginal & Torres Strait Islander
History of chronic condition: eg. New or chronic condition to continue >6 months
Identification of chronic condition/s
Goal of referral including priority concerns
Significant medical or social history

Additional Referral Information

Identification of acute services usage (Examples: >15 inpatient bed days, >10 outpatient specialist clinics in HHS, >6 Emergency Department presentations, >5 inpatient admissions (planned or unplanned), >2 readmissions within 28 days of discharge, >6 care providers involved in consumer care and/or social support

Send Referrals To

Smart Referrals

Nurse Navigator - Aboriginal and Torres Strait Islander

Secure Web Transfer

Not Available

Internal Referrals

Nurse Navigator - Aboriginal and Torres Strait Islander qhRefer

Fax

(07) 5687 4497

Post

Gold Coast University Hospital
1 Hospital Boulevard
Southport QLD 4215

Enquiries

Not available

Related HealthPathways

No directly related pathways found

HealthPathways home page

Service Availability

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.

Aboriginal and Torres Strait Islander Chronic Disease Nurse NavigationAdult