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.

We have heart (cardiac) rehabilitation programs that provide information to teach you how to manage your heart condition and support your recovery. The program is run by specialist nurses and health professionals.

You can take part in the exercise sessions run by physiotherapists that can help you to manage daily activities, fitness and heart health.

This service is accessed through Southern’s Central Intake Service (request “Cardiac Rehabilitation”).

In many cases you may self-refer, but some programs require health information or a referral from your GP or another health professional. The Central Intake team can advise what’s needed. 

For health professionals, referral forms and criteria are available on ACT and SNSW HealthPathways (search “Cardiac Rehabilitation” and select SNSW).

A local Diabetes Educator and Dietitian can provide a program tailored to your needs. They will help you build the skills and confidence to manage your diabetes day-to-day, including:

• healthy eating
• being active
• monitoring blood sugar levels
• taking medication
• problem solving
• coping with diabetes in healthy ways
• reducing health risk factors

This service supports anyone living with diabetes, including:

• people with pre-diabetes symptoms
• people newly diagnosed with diabetes
• women with diabetes in pregnancy
• all age groups affected by diabetes

Specialist clinics are available if you have more complex needs. These clinics provide advanced assessment and treatment planning.

You can access specialist diabetes care through the Nurse Practitioner Diabetes Service. Based at Queanbeyan Health Service, this mobile team visits Community Health Centres across Southern NSW every three months.

This service offers:

• comprehensive assessment and help with prioritising your care needs
• a plan for treatment, putting it in place, and reviewing how it’s working
• help managing your medications
• support to link with the right services across health sites and teams
• case management - working with other diabetes care staff
• referrals, if you need to see a diabetes medical specialist clinic

This service may benefit you if:

• you're aged 15 or older, and you have diabetes-related health concerns that standard community services can’t manage.
• you're at risk of going to the emergency department, or being admitted or readmitted to hospital, and would benefit from a care plan to reduce that risk.

This service is accessed through Southern’s Central Intake Service (request “Diabetes Team”).

In many cases you may self-refer, but some programs require health information or a referral from your GP or another health professional. The Central Intake team can advise what’s needed.

For health professionals, referral forms and criteria are available on ACT and SNSW HealthPathways (search “Routine Diabetes Team Referrals” and select SNSW).

Collaborating closely with St Vincent's Hospital Sydney Chronic Pain Service, our Pain Coordinators work with you and your local health team to:

• Provide advice, education and support to help you manage your pain
• Connect you with the right services, programs and health professionals
• Help you access specialist care, either locally or through virtual or face-to-face appointments at St Vincent's

If you've being living with pain for more than three months and it's impacting your daily life, speak to your GP or health professional about a referral to this service.
 

The service is available for people aged 16 and over who have experienced pain for more than 3 months that impacts daily life.

This service is accessed by referral from a health professional only through Southern’s Central Intake Service (request “Pain Coordination”).

For health professionals, a referral form and referral criteria can be accessed at ACT and SNSW HealthPathways, (search "Chronic Pain Management Referrals" and select SNSW).

• Adults with kidney disease across Southern NSW
• Children under 16 are not covered by this service; speak with your GP if your child needs renal care

Renal services for Southern NSW residents are provided through a formal partnership between Canberra Health Services and Southern NSW Local Health District. Our team of specialist renal doctors provide medical care, treatment, and support for people with kidney disease, and also attend regular renal clinics across Southern NSW.

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.

The Renal Outpatients Service is located at Building 15, Level 1, Canberra Hospital, Yamba Drive, Garran ACT 2605.

Your GP can refer you to Canberra Hospital to access renal care and local clinics across Southern NSW.

We provide local services across Southern NSW, including:

• Bulk-billed renal clinics at Bega, Goulburn, Moruya, Batemans Bay, Queanbeyan, and Cooma
• Visiting renal specialist doctors from Canberra Hospital
• Local support by a Renal Outreach Clinical Nurse Specialist, dietitian, and social worker
• Education and support on CKD management and treatment options
• Home dialysis support and training (managed by Canberra Hospital's Home Therapies Unit)
• In-centre haemodialysis where required

Bulk-billed renal clinics are available at Bega (South East Regional Hospital), Goulburn, Moruya, Batemans Bay, Queanbeyan, and Cooma. Clinics include visits from renal specialists from Canberra Hospital, with local support from a Renal Outreach Clinical Nurse Specialist.

Our Dialysis Units in Queanbeyan, Moruya, Bega, Goulburn, and Cooma provide in-centre haemodialysis. They are staffed by renal nurses and offer support to help you manage your treatment and promote self-care.

The Big Red Kidney Bus is a mobile dialysis service provided by Kidney Health Australia. It travels to coastal and regional destinations, including Southern NSW, allowing people on dialysis to enjoy a holiday while continuing their treatment. For locations, dates, and booking details, visit the Kidney Health Australia Big Red Kidney Bus page.

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

Our renal services are accessed by referral from a GP to the specialists at the Canberra Hospital Renal Service at Canberra Health Services.

For health professionals, a referral form and referral criteria can be accessed at ACT and SNSW HealthPathways, (search "Nephrology" and select SNSW).

Renal referrals are to be directed to the Canberra Hospital Renal Service for triage.

Phone: (02) 5124 2046
Fax: (02) 5124 7063
Email: ACThealthcentraloutpatient-referrals@act.gov.au

Alternatively, referrals can be made online through Canberra Health Services