Discharge Liaison Nurse Guidelines



Canberra Hospital and Health Services Operational Guideline Discharge Liaison Nurse GuidelinesContents TOC \h \z \t "Heading 1,1,Heading 2,2" Contents PAGEREF _Toc451164912 \h 1Guideline Statement PAGEREF _Toc451164913 \h 2Alerts PAGEREF _Toc451164914 \h 3Scope PAGEREF _Toc451164915 \h 3Section 1 – Discharge Liaison Nurse Role and Responsibilities PAGEREF _Toc451164916 \h 4DLN Role Outline PAGEREF _Toc451164917 \h 4DLN Responsibilities PAGEREF _Toc451164918 \h 5Section 2 – Patient Advocacy, Care Coordination and Referral PAGEREF _Toc451164919 \h 6Section 3 – Patient Education PAGEREF _Toc451164920 \h 9Section 4 – Discharge Documentation PAGEREF _Toc451164921 \h 10Section 5 – Key Performance Indicators for DLN PAGEREF _Toc451164922 \h 10Implementation PAGEREF _Toc451164923 \h 11Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc451164924 \h 11Search Terms PAGEREF _Toc451164925 \h 11Attachments PAGEREF _Toc451164926 \h 12Attachment A – Early Screen for Discharge Planning Algorithm PAGEREF _Toc451164927 \h 13Attachment B – Workplace Induction Pathway and Documents and Forms PAGEREF _Toc451164928 \h 14Attachment C – Community Nursing Services Contacts PAGEREF _Toc451164929 \h 15Attachment D – Hospital and Health Services Contacts PAGEREF _Toc451164930 \h 18Attachment C – Community Transport Contacts PAGEREF _Toc451164931 \h 19Attachment F – Aged Care Facilities Contacts PAGEREF _Toc451164932 \h 20Attachment G – Organisational Contacts PAGEREF _Toc451164933 \h 22Attachment H – Programs and Scheme Contacts PAGEREF _Toc451164934 \h 28Attachment I – Useful Links PAGEREF _Toc451164935 \h 29Guideline StatementBackgroundThe Discharge Liaison Nurse (DLN) Guideline has been developed to promote consistent, best practice discharge services and processes across all of Canberra Hospital and Health Services (CHHS). Consistent processes are important because they:Help ensure consumers and carers have a positive and safe experience moving from an acute care facility to their discharge destinationImprove efficienciesPresent a consistent view to consumers and carersAllow staff to more freely move between work areas and to support shortfalls as they occurImprove data collection and reportingAllow for services to be managed more effectively.DLNs are located in many clinical divisions across CHHS with some divisions incorporating discharge planning responsibilities into composite roles. Demand for DLN services is high and will continue to grow as:The population increases overall The population ages The number of patients with multiple co-morbidities increases The number of people living with chronic conditions increasesMore non acute services are safely provided from non-inpatient settings, andThe number and type of clinical services provided across the Territory increases.Operationally, DLN Level 2 positions report to nominated supervisory positions within their respective divisions. Key Objective The guidelines aim to balance the clinical requirements of consistent, safe and quality practice with the need to achieve higher levels of consumer input and satisfaction in discharge planning. In collaboration with the Multidisciplinary Team (MDT), the DLN is responsible for: the coordination and referral of discharge services for patients with complex needsensuring the discharge plan is patient centred, adheres to best practice and facilitates safe and timely transfer of care between the acute care setting and the discharge destination. Meeting the demand relies on all services optimising capacity. DLN’s play a vital role in supporting improvements in capacity, service efficiency and effectiveness, and consumer and staff satisfaction.Back to Table of ContentsAlertsPatients with complex needs requiring discharge support by the DLN are to be identified by the Ward Clinical Nurse Consultant (CNC) or delegate within 24 hours of admission and referred to DLNs by using the Early Screen for Discharge Planning Algorithm (see Attachment A). Patients scoring 10 or more should be referred to DLNs for review. Patients scoring below 10 are not routinely reviewed by the DLN. If staff are concerned however, a referral to a DLN can be made. Back to Table of ContentsScopeThis guideline outlines the role and responsibilities of the DLN and guides other multidisciplinary team (MDT) members involved in the discharge process. The guidelines also provide further procedural guidance for the majority of discharge services and lists Key Performance Indicators (KPI) assigned to the DLN role (please see Section 5 of this document). Where specific requirements necessitate further information and approaches, links to relevant documents are included. This resource guideline is targeted at DLNs managing complex discharges however has relevance to all staff involved in the discharge of patients across CHHS. A patient with complex needs in the discharge context is defined by using the Early Screen for Discharge Planning Algorithm (see Attachment A).ACT Health values of Care, Excellence, Integrity and Collaboration underpin the required approach to all discharge processes.Back to Table of ContentsSection 1 – Discharge Liaison Nurse Role and Responsibilities DLN Role OutlineThe DLN role encompasses the following core components to ensure safe and timely discharges of patients with complex needs from the acute care setting:Act as the communication link relating to the discharge process between relevant internal and external stakeholders and the patient and their family/carerWork independently and in conjunction with other health professionals to lead and coordinate safe, appropriate and timely discharge of patients to achieve expected date of dischargePatient advocacyReferral and coordination of patient care to receiving healthcare and community providers in consultation with MDT Team Initial and ongoing communication with relevant Community based health services for existing clients who have experienced an acute episode of care. This is to better facilitate a planned and safe discharge of the patient back to the community settingInitial communication with General Practitioner’s (GP) practice (including either the GP or the practice nurses) regarding discharge for patients acutely managed by the GP, immediately prior to admission or requiring GP follow-up on discharge Ensure the “What are they waiting for” criteria is progressing within the Estimated Day of Discharge (EDD) parametersConfirm and coordinate patient’s accommodation on discharge when needed in consultation with the MDT Coordinate equipment and supplies required by the patient ready for discharge in consultation with the MDT. Additional supplies may need to be considered if the patient is being discharged over public holiday periods.Confirm and coordinate if needed, Patient TransportProvide or coordinate patient education prior to discharge in conjunction with the appropriate subject matter expert/sProvide education to other staff, patients and carers on the role of the DLNConsider the need for the patient to be registered with “My Aged Care” or National Disability Insurance Association (NDIA) and provide assistance if requiredComplete relevant discharge documentation to inform:The patient or where relevant the Next of Kin (NOK), Primary Carer, Enduring Power of Attorney (EPOA), Health Attorney or GuardianThe receiving healthcare provider The patient medical recordPatients with complex needs requiring discharge support by the DLN are to be identified by the Ward Clinical Nurse Consultant (CNC) or delegate within 24 hours of admission and referred to DLNs by using the Early Screen for Discharge Planning Algorithm (see Attachment A). Patients scoring 10 or more should be referred to DLNs for review. Note:Use of Translator Services should be considered if English is not the patient’s first language.DLN ResponsibilitiesActs as the communication link relating to the discharge process between relevant internal and external stakeholders and the patientWithin the wardThe patientCNC and other ward staff Members of the MDTOther care providers With services established for the patient prior to discharge, for example:Community based Health providerResidential Aged Care facilitiesPalliative careGP Disability ServicesProviding education to other staff, patients and carers on the role of the DLN Orientation of all new staff to the ward including medical, nursing and allied health teams on the DLN role Small group education to promote and clarify DLN role Colleague to colleague training Mentoring of new and prospective staff to the DLN roleObservational opportunities organised by the DLN with specialised nursesComplex Care CNCCommunity Nursing TeamsChronic Care NurseCommunity Specialist CNC’sAcute Post Acute Care CNCContinence CNCWounds CNCCNC Stomal TherapySelf Management of Chronic Conditions,Community CDN’sCancer Nurse CoordinatorsEducation to patients and carers requiring complex discharge planning on the DLN role Position OrientationOrientation specific to the identified DLN positions is carried out by the DLN Team Leader in consultation with the area CNC. Please see Attachment B – Workplace Induction Pathway and Documents and Forms, for further information.Back to Table of ContentsSection 2 – Patient Advocacy, Care Coordination and Referral Patient advocacyAs a patient advocate, the DLN: Performs patient assessments – ensuring early identification of clinical issues and barriers to discharge in consultation with MDTFacilitates safe discharge to receiving facility or residence.Facilitates compliance with the patient’s stated wishes if achievable and safe.Fosters relationships with patients to build confidence that someone is identifying and coordinating ongoing care needs.Facilitates transfer of services to external government agencies, Non-government Organisations (NGO) and regional health services. Updates patient and carer on information relating to discharge processes. Is actively involved in family meetings in conjunction with the MDT.Referral and coordination of patient care to a receiving healthcare providerThe DLN makes the initial and subsequent contact with relevant agencies as required to ensure criteria for receiving patient are identified and where possible and reasonable are complied with including, but not limited to Community based Health services. Complex Care CNC’sCommunity Specialist CNC’sAcute Post Acute Care CNCContinence CNCWounds CNCCNC Stomal TherapyPalliative CareHospital in the Home (HITH)Specialist Nurses (in house) Cancer Care CoordinatorsDiabetic EducatorsStroke Liaison NurseStoma NurseChronic Care NursesSpecialist Mental Health NursesSpecialist Midwives Allied Health – public and privateSocial WorkersPhysiotherapistsOccupational TherapistsDietitians Speech PathologistsOtherRehabilitation Care CoordinatorPatients to be transferred to UCHVeteran Liaison – Eligible DVA Cardholders (Gold Card and some White Card holders) Arrange convalescent careOrder continence suppliesArrange transport for discharge and to follow up appointmentsApprove transport for interstate Veterans Provide information and forms for relevant DVA services and complete referrals as requiredLiaise with members of the MDT to optimise discharge outcomes Complete referrals to other ACT Health services for DVA patients such as Community Health Intake (CHI), LINK etc. Follow up phone call from Veteran Liaison to check services have commenced and are adequate Referral to DVA Allied Health providers and other health servicesGeriatric Care CoordinatorPatients to be transferred to ACE and 11BResidential Aged Care Liaison Nurse (RACLN) Aged Care Assessment Team (ACAT)Dementia Behaviour Management Advisory Services (DBMAS)Transitional Therapy and Care Program (TTCP) – early identification and referral to Social Work for organisation of ACAT assessment. Option of residential or home-based care.Aboriginal and Torres Strait Islander (ATSI) LiaisonGovernment AgenciesChild &Youth Protection Services/Family and Community Services (NSW) –child/baby/youth (also consider in cases where parents and carers are the patient and have dependent children at home).Newborn and Parent Support Service (NAPSS) – outlying hospitals/facilities, processesNDIAMy Aged CareGeneral PractitionersNon-Government Organisations (NGOs)Residential Aged Care Facilities Private hospitalsRegional ServicesEnsures the “What are they waiting for” criteria are progressing within the EDD parametersPharmacy Treatment ordersClinical intervention ordersDischarge summaryImagingPathologySame day outpatient appointments are scheduled after discharge timeMedical referralsConfirmation and co-ordination of accommodation on dischargeConfirm accommodation options and organise if required in conjunction with Allied Health staff. Home/usual residenceMedihotel – Note: the patient must be fully self-caring for this service.CHHS ResidencesCommunity HostelsStep-up, step-down facilities (adult and adolescence) (Please see the Step-Up Step-Down Residential Programs Guideline on ACT Health’s Policy Register)Regional Healthcare facilityResidential Aged Care FacilitiesOtherOrganise equipment and supplies required by the patient at the time of dischargeEnsure appropriate home oxygen is provided in consultation with the MDT (procurement – rent, purchase). For ACT residents, this process can be conducted through the Domiciliary, Oxygen and Support Scheme (DORSS), see ACT Domiciliary Oxygen and Respiratory Support Scheme (DORSS) procedure on the policy register. Ensure appropriate Bilevel Positive Airway Pressure (BIPAP), Continuous Positive Airway Pressure (CPAP) is provided in consultation with the MDT (procurement – rent, purchase). For ACT residents, this process can be conducted through the DORSS. Ensure appropriate hospital beds for home is provided in consultation with the MDT (procurement – rent, purchase). For ACT residents, this process can be conducted through the ACT Equipment Loan Service, see the ACT Equipment Loan Service procedure on the policy register.Ensure appropriate mobility aids and Activities of Daily Living (ADL) equipment provided in consultation with the MDT.Identification and initial provision of specialised dressings for use by Community NursesProvision of IDC, SPC consumables, incontinence supplies, statlock etc. for patient to take home to be used initially by Community Nurses or until patient can purchase.Provision of stoma supplies including ileostomy/colostomy for ongoing stoma care in consultation with the CNC Stomal Therapy. Home feeding supplies as required.Provision of Vacuum Assisted Closure (VAC) Therapy Dressing Consumables including portable VAC machine and canisters from Operating Theatres that go home with patients. Notify supplier that machine has been issued with patient details. Note: Some regional centres are unable to support VAC dressings and may also be responsible for ongoing care costs.Confirmation and co-ordination of Patient TransportConfirm transport options and organise if requiredFamily/carerCommunity transport – Note: Not available to discharge patient home, however might be an option for eligible patients requiring transport to Community Health Centres or Outpatient clinics.ACTRegionalACT Ambulance Services (ACTAS)NSW Ambulance Services (NSWAS)OtherPlease see Attachments C – I for a comprehensive list of service providers, contact numbers and useful linksAttachment C: Community Nursing ServicesAttachment D: Hospital and Health ServicesAttachment E: Community TransportAttachment F: Aged Care Facilities Attachment G: OrganisationsAttachment H: Programs and SchemesAttachment I: Useful LinksBack to Table of ContentsSection 3 – Patient Education DLN to coordinate patient education as required in conjunction with the appropriate subject matter expert, for example ChemotherapyCentral Venous Access Device (CVAD) managementChemotherapy precautionsBlood and blood productsNeutropenic precautions Diabetes managementRelevant patient educational handoutsSleep studies- facilitate equipment reviewVAC DressingsManagement of Percutaneous and Biliary drains and Nephrostomy TubesExpectation of Community based Health professionalsBack to Table of ContentsSection 4 – Discharge Documentation Complete and/or collate relevant discharge documentation To inform:The patient and receiving healthcare providerDischarge and Referral Plan for Community Services FormReferral/intake Community Health Clinical FormNursing Transfer FormOther documentation to be completed by a medical officer as required. If being transferred to another facility, the medical discharge summary must accompany the patientMedical Orders for Urinary Catheter Management FormMedical Officer Orders for Medication Administration FormMedical Officers Orders for Central Line Management FormTreatment Orders (Medical) Clinical FormMedical Officers Orders for Percutaneous Radiological Drain Management FormDischarge of a New Laryngectomy Patient to Home FormDischarge of a Patient with a Tracheostomy Tube to Home FormThe patient clinical recordPatient Care and Accountability Plan (Front page checklist to be completed by discharge nurse for complex discharges) Discharge and Referral Plan for Community Services Patient Transfer Form.All discharge related forms identified above can be found on ACT Health’s Clinical Forms Register.Back to Table of ContentsSection 5 – Key Performance Indicators for DLN Key performance indicators for DLNs are linked to the Early Screen for Discharge Planning Algorithm and are to be provided to the nominated supervisory positions within their respective divisions. Key performance indicators:The number of patients referred for DLN review who scored 10 or greater using the Early Screen for Discharge Planning AlgorithmThe number of patients seen by the DLN who scored under 10 using the Early Screen for Discharge Planning Algorithm. Written commentary to be included indicating reason for referralLong stay report – a report is to be provided on all patients exceeding a 15 day length of stay identifying the “what are they waiting for” criteria delaying discharge.Back to Table of ContentsImplementation This guideline will be communicated to all Executive Teams, Assistant Directors of Nursing, Directors of Nursing, Clinical Nurse Consultants and Discharge Liaison Nurses. The guideline will be incorporated into staff orientation and current DLN training workshops. Back to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationPoliciesAdministration of Hospital Admissions and Discharges Policy ProceduresDischarge Summary Completion procedureResidential Aged Care Facility Placement operational procedureAdmission to Discharge CHHS procedureACT Equipment Loan Scheme procedureACT Domiciliary Oxygen and Respiratory Support Scheme procedureGuidelinesStep-Up Step-Down Residential Programs GuidelineLegislationMental Health Act 2015Health Records (Privacy and Access) Act 1997Human Rights Act 2004Work Health and Safety Act 2011Back to Table of ContentsSearch Terms Discharge Liaison Nurse, Discharge RoleBack to Table of ContentsAttachmentsAttachment A – Early Screen for Discharge Planning AlgorithmAttachment B – Workplace Induction Pathway and Documents and FormsAttachment C – Community Nursing ServicesAttachment D – Hospital and Health ServicesAttachment E – Community TransportAttachment F – Aged Care Facilities Attachment G – OrganisationsAttachment H – Programs and SchemesAttachment I – Useful LinksDisclaimer: This document has been developed by ACT Health, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.Policy Team ONLY to complete the following:Date AmendedSection AmendedDivisional ApprovalFinal Approval 21/12/2017Minor ReviewMark Dykgraaf, ED Clinical OperationsCET Policy Team17/07/2019Phone numbers and UCH information updatedLiz Chatham, COOCET Policy TeamThis document supersedes the following: Document NumberDocument NameN/AAttachment A – Early Screen for Discharge Planning Algorithm5246370423418037985704314190 Attachment B – Workplace Induction Pathway and Documents and FormsThe following Workplace Induction Pathway checklist is available at: and Forms The following documents and form links are provided:Health Directorate Organisational Structure of Canberra Hospital (if applicable) workstation setup C – Community Nursing Services ContactsCOMMUNITY NURSING SERVICESAreaTelephoneFaxOther DetailsACTACT Community Health Intake02 6207 997702 6205 2611Belconnen02 6205 120102 6174 5530Calvary1300 797 52202 6251 7474E: ccc@.auCalvary John James02 6281 8100Canterbury (NSW)02 9787 059902 9787 0035Central/Civic02 6205 156802 6205 0712Phillip02 6205 214702 6205 2279Tuggeranong02 6205 274002 6205 1386Central CoastGosford02 4356 940002 4356 9401Central Tablelands - NSWBathurst02 6332 894302 6334 4931Blayney02 6368 900002 6368 3051Cowra02 6340 235602 6340 2490Orange02 6362 618402 6362 6127Central West - NSWDubbo - Lourdes Hospital and Community Health02 6841 850002 6885 899902 6855 1387Forbes02 6851 128802 6852 3078Parkes02 6861 250002 6862 1082Hunter New England HealthTaree02 6592 931502 6592 9607Illawara ShoalhavenIllawara Intake: Bulli, Nowra, Wollongong, Kiama, Culburra Beach, Milton, Berry, Bulli, Dapto, Sussex Inlet, Ulladulla1300 792 75502 4223 8455Cringila1300 792 75502 4223 8455Other Enquiries - 02 4274 0281Culburra1300 792 75502 4223 8455Other Enquiries - 02 4447 2055Dapto1300 792 75502 4223 8455Other Enquiries - 02 4261 4033Helensburgh1300 792 75502 4223 8455Other Enquiries - 02 4294 8044Jervis Bay1300 792 75502 4223 8455Other Enquiries - 02 4442 1093Nowra1300 792 75502 4223 8455Other Enquiries - 02 4424 6300 Nurse Manager - 0411402474St George Basin1300 792 75502 4223 8455Other Enquiries - 02 4443 7646Sussex Inlet1300 792 75502 4223 8455Other Enquiries - 02 4441 2373Ulladulla1300 792 75502 4223 8455Other Enquiries - 02 4455 5366Warilla1300 792 75502 4223 8455Other Enquiries - 02 4296 4200Wollongong1300 792 75502 4223 8455Other Enquiries - 02 4253 0300Wreck Bay1300 792 75502 4223 8455Other Enquiries - 02 4442 1255Mid North Coast Local Health DistrictPort Macquarie02 6588 288202 6588 2785The Rock02 6920 206602 6920 2502Murrimbidgee Local Health DistrictCoolamon02 6927 330302 6927 2477Cootamundra02 6940 111102 6940 1199Other Fax No: 02 6386 2931Corowa02 6033 755502 6033 7601Griffith02 6966 990002 6964 1743Gundagai02 6944 129702 6944 1878Harden02 6386 220002 6386 3559Leeton02 6953 11102 6953 120502 6953 1214Mercy Care Centre Young02 6382 844402 6382 8400Quandialla02 6347 120002 6347 1245Temora02 6980 020002 6977 1545Tumbarumba02 6948 960002 6948 2263Tumut02 6947 181102 6947 2220Wagga Wagga02 6938 637702 6938 662202 6938 6410Young Oncology Service02 6382 848502 6382 8792North West - NSWGunnedah02 6741 800002 6740 2879Southern Highlands - NSWBowral1800 455 51102 4621 8799Southern NSWAdelong02 6946 205502 6946 2041Albury02 6058 180002 6058 1801Australian Unity Home Care Services - NSW, QLD, VIC1300 160 170Batemans Bay1300 139 8871300 669 370Other Enquiries: 02 4475 1620Bega02 6492 96201300 797 331Other Fax No: 02 6492 3257Bega Valley Intake: Bega, Pambula, Eden, Wyndham, Tura Beach02 6492 96201300 797 331Bombala02 6458 577702 6458 5767Boorowa02 6385 345002 6385 3206Braidwood02 4842 256602 4842 2054Bungendore02 6238 133302 6238 1656Cooma Intake: Adaminaby, Berridale, Jindabyne, Thredbo, Kalkite02 6455 320102 6455 3360Crookwell02 4832 130002 4832 209902 4832 2903Delegate02 6458 800802 6458 8156Eden02 6496 143602 6496 1452Eurobodalla: Batemans Bay, Narooma, Cobargo, Bermagui, Moruya, Tuross Heads, Dalmeny, Surf Beach, Tomakin1300 139 8871300 669 370Goulburn02 4827 391302 4827 3943Gunning / Sutton02 4845 116602 4845 1542Jindabyne02 6457 207402 6457 2158Merimbula/Pambula02 6495 72941300 797 331Moruya1300 139 88702 447415621300 669 370Other Enquiries: 02 4474 1561Narooma1300 139 8871300 669 370Other Enquiries: 02 4476 2344Queanbeyan Community Nurse02 6298 923302 6299 6920Other Numbers - 02 6298 9219,0408163761Queanbeyan Home Care1300 881 14402 6200 7300Yass02 6220 211102 6220 2116SydneySouth West Sydney Community Nursing1800 455 51102 4621 8799Sydney District Nursing1300 722 276VictoriaEast Grampians03 5352 932803 5352 9425Indigo North Health02 6033 626603 6033 6265Mallacoota03 5158 024303 5158 0448Mildura - Sunraysia Community Health03 5022 544403 5022 5445Wodonga03 6051 711103 6051 7404Western NSWDunedoo02 6375 140802 6375 1221Grenfell02 6349 177702 6343 2014Attachment D – Hospital and Health Services ContactsHOSPITALS & HEALTH CENTRESNameTelephoneFaxAddressAlbury Wodonga Health - Albury Campus02 6058 444402 6058 4680Borella Road Albury NSW 2640Albury Wodonga Health - Wodonga Campus03 6051 711103 6051 747769 Vermont Street Wodonga Vic 3690Batemans Bay District Hospital02 4475 150002 4472 06787 Pacific Street Batemans Bay NSW 2536Batlow Hospital02 6941 433302 6941 433161 Pioneer Street Batlow NSW 2730Blayney Hospital02 6368 900002 6368 30513 Osman Street Blayney NSW 2799Bombala Hospital02 6458 577702 6458 3759126-128 Wellington Street Bombala NSW 2632Boorowa District Hospital02 6385 300402 6385 320662-80Dry Street Boorowa NSW 2586Braidwood Hospital02 4842 256602 4842 205477 Monkittee Street Braidwood NSW 2622Calvary John James02 6281 8100173 Strickland Crescent Deakin NSW 2600Cooma Hospital02 6452 322202 6452 2117Bent Street Cooma NSW 2630Cootamundra Hospital02 6942 0444Mackay Street Cootamundra NSW 2590Cowra District Hospital02 6340 230002 6340 233164 Liverpool Street Cowra NSW 2794Crookwell02 4832 130002 4832 209917 Kialla Road Crookwell NSW 2583Delegate Hospital02 6458 800802 6458 815615 Craigie Street Delegate NSW 2633Forbes Hospital02 6850 2000Elgin Street Forbes NSW 2871Ginninderra Medical and Dental Centre02 6112 711102 6112 7112Nettlefold Street Belconnen ACT 2617Goulburn HITH02 4827 310402 4827 3926Goulburn Hospital02 4827 311102 4827 3248130 Goldsmith Street Goulburn NSW 2580Grenfell Hospital02 6349 170002 6343 176280-96 Cowra Road Grenfell NSW 2810Griffith Hospital02 6966 5555Warrambool Street Griffith NSW 2680Gundagai Hospital02 6940 630050 Tor Street Gundagai NSW 2722Gunnedah Hospital02 6741 800002 6740 2879Marquis Street Gunnedah NSW 2380Hay Hospital02 6990 8700351 Murray Street Hay NSW 2711Leeton Hospital02 6953 111102 6953 120502 6953 12141 Myall Street Leeton NSW 2705Moruya District Hospital02 4474 266602 4474 15862-10 River Street Moruya NSW 2537Murrumburrah-Harden District Hospital02 6386 220002 6386 293154 Swift Street Harden NSW 2587Pambula District Hospital02 6495 600202 6495 6570Merimbola Street Pambula NSW 2549Queanbeyan District Hospital02 6298 921102 6299 153616 Erin Street Queanbeyan NSW 2620South East Regional Hospital - Bega02 6491 92221556 Tathra Road Bega NSW 2550Tumut District Hospital02 6947 080002 6947 3074Simpson Street Tumut NSW 2720Wagga Hospital02 6238 6666Edward Street, Wagga NSW 2560Winnunga Nimmityjah - Aboriginal Health Centre02 6284 622202 6284 620063 Boolimba Crescent Narrabundah ACT 2604Yass District Hospital02 6220 200002 6226 2944Meehan Street Yass NSW 2582Young District Hospital02 6382 888802 6382 439868 Allanan Street Young NSW 2594GP Phillip Medical and Dental Centre02 6112 700002 6112 711133 Colbee Court Phillip ACT 2606Attachment C – Community Transport ContactsCOMMUNITY TRANSPORTNameTelephoneFaxEmailService HoursCostsOther InformationACT Government Flexible Bus Service02 6205 3555flexiblebusservice@.auMon-Fri 9am-4pmFreeFor seniors and people with a disability only. Bookings to be made two days prior to travelBega Valley Community Transport02 6492 418802 6492 4174bookings@.auMon- Fri 7am-5pmNegotiable upon bookingTwo working days noticeBelconnen Community Transport Service02 6251 288602 6264 020002 6253 2901bcs@.au9am - 4pmTransport assistance available: 7am-7pm, 7 days a week$5 per day$15per week capFor aged and people living with a disability to access medical and paramedical appointments, shopping etc.Cooma Community Transport02 6451 1054Eurobodalla Community Transport Service02 4474 10401800 755 760(After Hours)02 4474 1028contactcentre@esc..auMon-Fri, 8.30am-4.30pmGunghalin Community Transport Service02 6126 9090transport@Mon-Fri$4 within Gungahlin each way$5 outside Gungahlin each wayLeukaemia Foundation02 4967 290602 4960 2906g@cameron@.auFlexible depending on where the patient livesFree - patient needs to be registered with the FoundationFax is preferred method for bookings. Need 48hours notice for bookingsNorthSide Community Service02 6247 575702 6257 2255N/Ancsintake@northside.asn.au SouthSide Community Service02 6126 4780Mon-Fri 9am - 3pmGold Coin donationWeston Creek - Tuggeranong02 6293 6500N/Atransport@8am-5pm$6 one way or returnAttachment F – Aged Care Facilities ContactsAGED CARE FACILITIESNameTelephoneFaxAddressEmailContact PersonServicesAdria Village02 6288 019802 6288 763589 Fremantle Drive Stirling 2611admin@.auResidential Respite & Permanent PlacementBaptist Care Griffith02 6195 660002 6295 782445 Stuart Street Griffith 2604Brindabella Gardens02 6285 191702 6282 359838 Theodore Street Curtin 2605janet.nelson@.auJanet NelsonResidential Respite & Permanent PlacementBupa Calwell02 6298 520002 6298 523343 Were Street Calwell 2905admincalwell@.au Residential Respite & Permanent PlacementBupa Stirling02 6287 020002 6287 023341 Fremantle Drive, Stirling 2611adminstirling@.au Residential Respite & Permanent PlacementBurrangiri Centre02 6288 148802 6288 03211-7 Rivett Place Rivett 2611Respite CentreCalvary Haydon Retirement Community02 6264 740002 6264 74962 Jaeger Circuit Bruce 2617Residential Respite & Permanent PlacementCarey Gardens Centre for Aged Care02 6195 300002 6239 7927111 Carnegie Crescent Red Hill 2603jdexter@.auJill DexterResidential Respite & Permanent PlacementClare Holland House02 6264 730002 6273 03385 Menindee Drive Barton 2600Palliative CareCommonwealth Respite and Carelink Centres1800 052 222Eabrai Lodge Special Care Hostel02 6288 479912 Namatijira Drive Weston 2611Permanent PlacementGeorge Forbes House02 6151 690002 6297 6982Cnr Erin & Collett Streets Queanbeyan NSW 2620Ginninderra Gardens Nursing Home and Hostel02 6123 9000 / 026255 258823 Burkitt Street Page 2614Residential Respite & Permanent PlacementGoodwin Aged Care - The Central02 6175 505720 Galore Street Crace 2911Retirement VillageGoodwin Aged Care Ainslie02 6175 500135 Bonney Street Ainslie 2602Goodwin Aged Care Farrer02 6286 1766 /6175 510122 Marshall Street Farrer 2607Residential Respite & Permanent PlacementGoodwin Aged Care Monash - David Harper House02 6178 720015 Cockcroft Avenue Monash 2904Goodwin Aged Care Monash - Ralph Cartwright Centre02 6175 5601 /6291 453327 Cockcroft Avenue Monash 2904Horton House and Warmington Lodge02 6226 309002 6226 609341 Castor Street Yass NSW 2582admin@.auIllawara Retirement Trust1800 024 91502 4221 668877 Market Street Wollongong NSW 2500Kalparrin Aged Care Facility02 6254 254402 6254 7080138 Hardwick Crecent Holt 2615Residential Respite & Permanent PlacementKangara Waters02 6233 82662 Joy Cummings Place, Belconnen 2617Residential Respite & Permanent PlacementKankinya Aged Care Facility02 6247 398848 Archibald Street Lyneham 2602Residential Respite & Permanent PlacementLinton Village02 6226 189926 Mount Street Yasscarole.heath@.auMorling Lodge Nursing Home02 6112 060051 Hicks Street Red Hill 2603Residential Respite & Permanent PlacementMorshead Home Hostel and High Level02 6263 950002 6247 165326 Archibald Street Lyneham 2602Residential Respite & Permanent PlacementMountain View Aged Care Facility02 6295 104402 6295 1473Cnr Goyder Street and Leahy Close Narrabundah 2604Residential Respite & Permanent PlacementSouthern Cross Care02 6260 425602 6230 19227 Boake Place Garran 2605Residential Respite & Permanent PlacementSouthern Cross Care Campbell02 6248 54322 White Crescent Campbell 2612Permanent PlacementSt Andrews Village Harrison House/John Flynn House02 6283 499902 6281 429181 & 95 Groom Street Hughes 2605info@.auResidential Respite & Permanent PlacementSt Nicholas' Home for the Aged02 6295 189102 6295 38031 Gosse Street, Kingston 2604admin@.au flepavoux@.auFran Le PavouxResidential Respite & Permanent PlacementUniting Care Mirinjani Nursing Home02 6288 430002 6288 427815 Conder Street Weston 2611Nursing HomeUniting Care Mirinjani Retirement Village/Residential Respite02 6288 441102 6287 128811 Namatjira Drive Weston 2611jdowell@Retirement Village & Residential RespiteUpper Jindalee Nursing Home02 6239 680002 6239 6686277 Goyder Street Narrabundah 2604admissions@.auNursing HomeVillaggio Sant' Antonio Hostel02 6255 179402 6254 076635 Burkitt Street Page 2614care@.au clinical@.auKerry Little-John (for care email)Julie (for clinical email)Residential Respite & Permanent PlacementAttachment G – Organisational ContactsORGANISATIONSNameTelephoneFaxEmailAddressACT Government ServicesAinslie Village02 6162 680023 Quick Street Campbell ACT 2612Belconnen Community Service02 6264 020002 6253 290126 Chandler Street Belconnen ACT 2616Calvary Breast Care Nurses02 6201 6672breastcarenurses@calvary-.auHaydon Drive Bruce ACT 2617Calvary Chemotherapy Clinic - Zita Mary02 6201 664502 6201 6181Belconnen Way & Haydon Drive Bruce 2617Equipment Loan Service02 6207 065802 6205 2604equipmentloanservice@.au37 Kingsmill Street Kambah 2902 ACTFamily Services1300 556 729Gungahlin Regional Community Service02 6242 6077Home Help ACT02 6287 377727 Mulley Street Holder ACT 2611Mobility Matters02 6280 724402 6239 128135 Townsville Street Fyshwick ACT 2609Mobility Parking Permits02 6207 700013-15 Challis St Dickson ACT 2602Northside Community Services02 6257 225502 6257 59932 Rosevear Place Dickson ACT 2602Older Persons Mental Health Service02 6205 195702 6205 1533Public Trustee for ACT02 6207 9800221 London Circuit Canberra City 2600Southside Community Services02 6126 470002 6295 7944admin@.au63 Boolimba Cresent Narrabundah ACTWoden Community Services02 6282 264402 6285 1322enquiries@.au26 Corinna Street Woden ACT 2606ChemistsAmcal Chemist Cooleman Court Chemist02 6288 1867Cooleman Court Brierly Street ACT 2611Capital Chemist Bruce02 6251 304402 6251 1055Ginninderra Drive Bruce ACT 2617Capital Chemist Calwell02 6292 820002 6292 8973Were Street Calwell ACT 2905Capital Chemist Charnwood02 6258 494902 6258 7517Lhotsky Street Charnwood ACT 2615Capital Chemist Chisholm02 6292 242702 6292 3262Halley Street Chisholm ACT 2905Capital Chemist Curtin02 6281 105802 6258 347042 Curtin Place Curtin ACT 2605Capital Chemist Dickson02 6248 768402 6248 7899Dickson Place Dickson ACT 2602Capital Chemist Higgins02 6254 048402 6254 0086Higgins Place Higgins ACT 2615Capital Chemist Hughes02 6281 258102 6281 2044Hughes Place Hughes ACT 2605Capital Chemist Isabelle Plains02 6292 111102 6292 2222Ellerston Avenue Isabella Plains ACT 2905Capital Chemist Kambah02 6231 701402 6231 1271Kambah Village, Kambah ACT 2902Capital Chemist Kingston02 6295 914602 6232 608558 Giles Street Kingston ACT 2604Capital Chemist Lyneham02 6247 700402 6249 8912Wattle Street Lyneham ACT 2602Capital Chemist O'Connor02 6248 705002 6257 4724Sargood Street O'Connor ACT 2602Capital Chemist Palmertson02 6241 971002 6241 9496Kosciusko Avenue Palmerston ACT 2913Capital Chemist Southlands02 6286 364402 6286 6723Mawson Place Southlands ACT 2607Capital Chemist Tuggeranong02 6293 275002 6293 4596Tuggeranong Square Tuggeranong ACT 2900Capital Chemist Wanniassa02 6231 644602 6231 971612 Sangster Place Wanniassa ACT 2903Capital Chemist Waramanga02 6288 134402 6287 1588Damala Street Waramanga ACT 2611Erindale Pharmacy02 6231 655011 Wanniassa ACT 2903Equipment/Home Modification/Home Help CompaniesBOC Healthcare Australia1300 732 695bocsleepcare@Chubb Security13 15 9813 15 18Duo02 6287 2870Grey Army02 4295 350002 4295 37002 Memorial Drive Shellharbour NSW 2529Home Flexi Care02 6239 599402 6239 4516111 Carnegie Crescent Red Hill 2603INS Lifeguard - Personal Monitoring and Alarm1800 636 22611 West Street Wollongong NSW 2526Just Better Care1300 587 82302 6280 407041-45 Tennant Street Fyshwick 2609Kincare1300 733 5101300 733 520act@.au17 Napier Close Deakin ACT 2600Oxygen - Air Liquide Healthcare02 6285 297902 6244 3952Equinox 3, 22-70 Kent Street Deakin ACT 2606RDNS Peronal Alarm - Doctors Safety Line08 8354 0155797 Port Road Woodville SA 5011Red Cross Emergency Home Alarm02 6234 763402 6234 76673 Dann Close Garran ACT 2605Tunstall - Personal Medical Alarm1800 603 3771800 435 570customer.service@tunstallhealthcare.co985 Kingsford Smith Drive Eagle Farm 4009Uniting Home Care ACT/Southern Tablelands1800 486 48402 8836 664427-29 Napier Close Deakin ACT 2600Federal DepartmentsCentrelink13 62 4013 Lonsdale Street Braddon ACT 2612Department of Veterans Affair1800 555 25428-20 Corinna St Woden ACT 2606DVA Rehabilitation Appliances Program133 254Translating and Interpreting Services131 450tis@.au2 Lonsdale Street Melbourne 3000Meal Delivery ServicesACT Home Style Catering02 6278 3166Holt Shopping CentreDelectables Direct02 6228 1034Doorstep Dinners0407 668 647victoria@.auGourmet Dinner Service1300 131 07002 9905 0668info@.auBrookvale NSW 2100Lite n Easy131 512Meals on Wheels02 6287 4311NSW GovernmentEnable NSW1800 362 25302 8767 6543enable@health..auSupport Groups/ NGOsAbbeyfield Australia - Ainslie02 6257 530702 6254 247575 Wakefield Gardens Ainslie ACT 2602Abbeyfield Australia - Garran02 6332 539815 Stephens Place Garran ACT 2605ACT Deafness Resource Centre02 6287 439302 6287 4394enquiries@.au27 Mulley Street Holder 2611ACT Disability, Aged and Carer Advocacy Servi02 6242 506002 6242 5063adacas@.auPhillip Avenue Watson ACT 2602ACT & Districts Stoma Association02 6205 105502 6207 9977actstoma@.au1 Moore Street Canberra 2601ACT Multicultural Council02 6162 1394Alzheimers Association02 6255 072202 6255 0499helpline.act@.au159 Maribyrnong Avenue Kaleen ACT 2617Australian Breastfeeding Association ACT02 6162 2716abaact@.au3/70 Maclarium Cr Chifley ACT 2606Baptist Care1300 275 22702 9023 .auBaulkham Hills NSW 2153Barnardos Australia02 6228 950002 6241 4560canberra@.au2 Atherton Street Downer ACT 2602Australian Red Cross02 6234 760002 6234 7650actinfo@.au3 Dann Close Garran ACT 2605Canberra After Hours Locum Medical Service02 6288 171102 6285 1811admin@.auPO Box 5066 Garran ACT 2605Canberra Blind Society02 6247 458002 6247 2927canblind..auGriffin Centre Genge St ACT 2601Canberra Glaucoma Support Group02 6241 834345 Florentine Circuit Kaleen ACT 2617Canberra Grief Centre0409 966 515 -Sonia0401 344 577 -Mandysonia@.au mandy@.au21 Napier Close Deakin ACT 2600Canberra Rape Crisis Centre02 6247 2525crcc@.auPO Box Weston Creek 2611 ACTCancer Council02 6257 999902 6257 50555reception@5 Richmond Avenue ACT 2609Cancer Support Group02 6297 126102 6297 1878csg2@21 Cooma Street QueanbeyanCare Financial Counselling02 6257 178802 6257 1452admin@2 Akuna Street Canberra CityCarers ACT1800 242 63602 6296 999980 Beaurepaire Crescent Holt ACT 2615Communities at Work Head Office - WestonCreek & Tuggeranong02 6293 650002 6293 6553245 Cowlishaw Street Greenway ACT 2900Community Connections02 6296 113302 6296 1134admin@.au21 Jenke Circuit Kambah ACT 2902Community Gateway Bungendore0431 184 96902 4422 50762 Majara Street Bungendore NSW 2621Community Gateway Crookwell0401 305 14102 4422 507648 Denison Street Crookwell NSW 2583Community Gateway Nowra02 4428 730002 4422 507669 Berry Street Nowra NSW 2541Community Gateway Wollongong02 4226 361102 4229 466826 Atchison Street Wollongong NSW 2500Community Options ACT02 6295 880002 6295 8100admin@.auGPO Box 3067 Canberra ACT 2601Companion House Assisting Survivors ofTorture and Trauma02 6251 4550info@.au41 Templeton Street Cook ACT 2614COTA ACT02 6282 377702 6285 3422contact@.auHughes Community Care, Wisdom Street Hughes ACTCPAP Australia1300 692 72770 Kent Street DeakinDementia Behaviour Management AdvisoryServices1800 699 799159 Maribyrnong Avenue Kaleen ACT 2617Dental Emergency Services02 6207 9977Diabetes ACT02 6288 983002 6288 9874diab@diabetes-.au17 Barry Drive Turner ACT 2612Diabetes Nursing1300 733 510mail@.auDirections ACT02 6132 480002 6132 4801reception@Level 6 Cosmopolitan Centre Woden SquareDomestic Violence Crisis02 6280 0900cw@.auFitness for over 50s (YMCA)02 6230 622402 6230 6284admin.canberra@.au7/100 Matiland St Hackett ACT 2602Galilee02 6290 21912 Collett Place Pearce ACT 2607House With No Steps - Disabiliy Service02 6195 777702 9452 5932Leukaemia Foundation1800 620 420info@.auMental Health Foundation ACT1800 985 94402 6282 6674info@.au 11/70 MacLaurin Crescent Chifley ACT 2602Migrant and Refugee Settlement Services ACT02 6248 8577180 London Circuit Canberra ACT 2601Mobile Respite Response Team02 6255 072202 6255 0499act.admin@.au159 Maribyrnong Avenue Kaleen ACT 2617Multiple Sclerosis Society ACT02 6234 700002 6234 7099actreception@.au117 Denison St Deakin ACT 2600Ngunnawal Community Care02 6226 3799Shannon House, 147 Meehan Street, Yass, NSW, 2582Palliative Care ACT02 6255 5771office@.au5 Flemington Road Lyneham ACT 2602Paraquad02 8741 560002 8741 5650paraquad@.auParkinsons ACT02 6290 1984parkinsons@.auGPO Box 717 Mawson ACT 2607Queanbeyan Multilingual Centre02 6297 611002 6297 0386info@.au12 Rutledge Street Queanbeyan NSW 2620Relationships Australia1300 364 277Respite Care ACT02 6288 0955Safety Link - Personal Response Service1800 813 6171800 193 233info@.au16 Eastwood Street Ballarat Central VIC 3350Samaritan House02 6284 5150samhouse@sdvp-cg-org.auSexual Health and Family Planning02 6247 307702 6257 5710shfpact@.au 28 University Avenue Canberra ACT 2601SIDS ACT02 6287 425502 6287 4210admin@70 Maclaurin Crescent Chifley ACT 2606Sleep Apnoea Association ACT02 6290 1984PO BOX 1461 Tuggeranong ACT 2901Sleep and Lifestyle Clinic02 6162 1802reception@.au61 Dundas Court Philip ACT 2606Sleep Disorders Australia - NSW Branch02 9990 3514Stroke Association02 6269 2636Deakin West 49 2600Women's Information and Referral Centre02 6205 107502 6205 1706wirc@.auPO Box 158 Canberra 2601Telephone ServicesBaptist Care Call1300 130 10002 9870 8640carecall@.auBreastfeeding Helpline1800 686 268Centrelink Multilingual Phone Service131 202Continence Foundation of Australia - Hotline1800 330 066helpline@.au 30 Sydney Road Brunswick VIC 3056Dementia Helpine1800 100 500helpline.act@.au Health Direct Australia1800 022 222Health First02 6207 7777Lifeline Canberra13 11 14Office - 02 6215940002 6215 940171 Northbourne Avenue Canberra 2601Medicines Line1300 633 424Mens Line Australia1300 78 99 78Office - 03 83712800Telecross1300 885 698Tresilian Parent Helpline1300 272 736Vital Call1300 360 808customer.service@.au Attachment H – Programs and Scheme ContactsPROGRAMS & SCHEMESProgram/SchemeOrganisationTelephoneFaxEmailCIT Skills for CarersMental Health Foundation ACT02 6207 362802 6207 4839carerskills@cit.edu.auContinence Aids Payment SchemeDepartment of Health02 6269 100002 9895 3525caps.processing@.auNational Carer Counselling ProgramCarers Australia1800 242 636Post Hospital Support ProgramCommunity Options02 6295 880002 6295 8100admin@.auTaxi Subsidy SchemeACT Government02 6207 193002 6205 1012acttaxischeme@.auTransitional Therapy and Care ProgramACT Government/Baptist Care02 6207 0658Veterans Home Care ProgramDepartment of Veterans Affairs1300 550 450generalenquiries@.auAttachment I – Useful LinksHealth Directorate IntranetSpend time getting to know this site and its various links. It will help you to learn more about the organisation, as well as learning about some useful reference material. This site is used for all room and equipment bookings in the Canberra Hospital campus. It also contains information on the process used to book a government car. Government DirectoryThis is a very useful site to know. Amongst other functions, this site has a search engine that can help you to locate the contact details of anyone working for the ACT Government. You will probably find yourself frequently using this web page, so it may be a good idea to create a shortcut to the site for easy access. Directorate WebsiteThis is the public web face of the Health Directorate. It is useful to know what information it provides. and Interpreting Services (TIS)ACT Government policy requires that services and programs provided by the ACT Government are responsive to the needs of clients who are unable to communicate effectively in English.Under this policy ACT Health has a responsibility to ensure that staff act on the obligation to provide effective, efficient and inclusive services through appropriate use of professional interpreters for people who are not proficient in English. Support /Multicultural Health /Interpreting ServicesChief Minister and Treasury DirectorateThe site has numerous useful links. Spend some time familiarising yourself with the site. It has links to some good documents. For instance, Industrial Relations, Public Sector Management, and Policy & Strategic Direction information can be found here. LegislationThis site provides access to all ACT legislation and subordinate legislation, as well as bills introduced in the Assembly, exposure bills, repealed legislation and other useful bits and pieces. of HealthThe web address for the Commonwealth Department of Health is: Connect WebsiteProvides access to a comprehensive range of ACT Government information and services including business, community, education, employment and other information. ................
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