Nurse Navigation of Complex Patients
Adult

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Emergency Referrals

Useful Management Information

Complex Care is a community-based service that encompasses the Complex Discharge Service (CDS) and Complex Care Nurse Navigation (CCNN). CCNN is a team of advance practice generalist nurses who are focused toward promoting appropriate utilisation of health resources, implementing reablement support to improve consumer engagement and self-efficacy, and strengthening cross sector partnerships and communication to optimise care continuity.

Please note that CCNN is a navigation service and is not a service provider nor a restorative care program. Consider Chronic Disease Management Plan eligibility or recommending patient/carers seek independent financial advice, advice via Centrelink.

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 public medical specialist.

Complex Care Nurse Navigation can assist with:

Collaboration with GPs and NGOs for service linkage and navigation
Specialist allied health psychosocial and functional assessment and referrals
Linkage with ongoing NGO consultancy services, service providers to support and overcome barriers to access support in the community
Aged care & disability navigation
Health literacy education and health coaching
Development of shared management plans for hospital alternative care, including advance care planning and Emergency Department Acute Management plan
Medication adherence issues
Poor understanding of health needs
Insufficient support to meet care needs due to self-care deficits, poor health literacy or low literacy skills, language or cultural barriers
Frequent inappropriate utilisation of health services
Disengagement with health services
Poor communication across sectors and/or partners in care
Carer stress
Social isolation

Minimum Referral Criteria

Does your patient meet the minimum referral criteria?

Category 1 (appointment within 30 calendar days)	Have complex needs that require active management to support engagement, access, service optimisation and wellbeing Have insufficient supports to sustain current need in the community At imminent risk of non-acute hospital utilisation
Category 2 (appointment within 90 calendar days)	No category 2 criteria
Category 3 (appointment within 365 calendar days)	No catgeory 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

Patient/decision maker agreeable to referral
Patient has a nominated GP

Additional Referral Information

Specialist letters
Team Care Arrangement
Advance Care Planning
NDIS or My Aged Care assessment and plan

Send Referrals To

Smart Referrals

Preferred Method
About Smart Referrals

Secure Web Transfer

Medical Objects Account: GQ42150009Z

HealthLink EDI: Qldgchsd

Internal Referrals

Complex Care Nurse Navigators qhRefer

Fax

(07) 5687 4497

Post

Booking and Referral Centre
Gold Coast University Hospital
1 Hospital Boulevard
Southport QLD 4215

Enquiries

1300 559 083

Related HealthPathways

No directly related pathways found

HealthPathways home page

Service Availability

Dr Claudia Wong

Medical Director Complex Care Team

Facilities

Robina Health Precinct

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.

Nurse Navigation of Complex PatientsAdult