CHRONIC DISEASE
MANAGEMENT.
Living with a long-term condition is mostly managed at home by yourself.
A nurse who knows how to manage your condition can make that time a lot less lonely.
Heart failure, chronic obstructive pulmonary disease and diabetes have one thing in common. The hospital sees them for a few days, and you live with them for the rest of the year. Our nurses work in that gap, helping you understand what is happening, spot a flare before it becomes an admission, and keep the people treating you properly informed.
This is not a replacement for your GP, your cardiologist or your respiratory team. It is the regular contact in between, from someone who knows what your normal looks like and will notice when it changes.
Patients & Families
For referrers and Support Coordinators
Funding Options for
chronic disease management.
Funding Options
Call 1800 678 647 and we will help you check.
Not Sure What Fits Your Plan?
1800 678 647
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Fill in an enquiry form.
We Can't Wait to Meet You
Conditions We Support
01
Chronic Heart Failure
Also called congestive cardiac failure. Daily weight and fluid monitoring and what the numbers are telling you, understanding the fluid and salt advice you have been given, medication support, and knowing which symptoms mean call the GP today and which mean call an ambulance. Most heart failure admissions are preceded by several days of warning signs that nobody read as warning signs.
02
Chronic Obstructive Pulmonary Disease (COPD)
Inhaler and spacer technique checked properly, because a large share of people are not getting the dose they think they are. Breathing and energy conservation strategies for the parts of the day that are hardest, oxygen support where it is prescribed, and working through your written COPD action plan so a flare-up gets treated on day one rather than day four.
03
Diabetes
Blood glucose monitoring and what the pattern means, insulin and oral medication support, foot and skin checks, and sick day planning, which is the thing most people are never told about and most often need. Type 1, type 2 and steroid-induced, in adults and in people with disability where the routine has to fit around everything else.
04
Other Conditions
What Support Looks Like
Who This Support Helps
What our nurse
do not do
Our nurses do not:
- diagnose
- prescribe
- change your treatment
Medication changes, referrals and clinical decisions must be made by your GP, your specialist team or your surgeon.
What our nurses do is help you follow the plan you have been given, notice when something is not going to plan, and make sure the treating team hears about it early.
Chronic Disease Management Through the NDIS
Where a participant has a long-term condition, most of the day to day management sits with the people around them, and how well that goes usually depends on whether anyone has written down what to watch for. Regular nursing contact and a written action plan give the support team something specific to act on rather than a general instruction to keep an eye on things.
For providers, a participant with repeat admissions is a difficult thing to evidence. A documented record of what was observed, what changed and what was escalated is more use at a plan reassessment than a description of how the year went.
When support needs have changed.
Where a condition has progressed, or admissions have become more frequent, ongoing nursing review can help identify and document that change. Nursing review is not an NDIS assessment and does not determine funding decisions. The findings may still help participants and their support teams gather evidence to support a Change of Circumstances application or plan reassessment where appropriate.
We cannot promise a particular plan outcome. What we can do is make sure the people making those decisions are working from something written down and current.
For providers, a participant with repeat admissions is a difficult thing to evidence. A documented record of what was observed, what changed and what was escalated is more use at a plan reassessment than a description of how the year went.
Optimum NDIS
Referrals.
Optimum NDIS
Referrals.
If you are a Support Coordinator, LAC officer, Plan Manager or another health care professional and you would like to submit a referral for one of your participants, please select one of the below options.
Get in Touch.
12 clinics across NSW & Tasmania
Email us
hello@opt.net.au
Speak to us
1800 678 647
Locations
Telehealth
Available everywhere for everyone.
In Your Home
Illawarra
Horsely
Dapto
Wollongong
Shellharbour
Albion Park
Kiama
SOUTH COAST
Nowra
Shoalhaven
SOUTH WEST SYDNEY
Moorebank
Liverpool
Warwick Farm
Casula
Chipping Norton
Wattle Grove
Where to Access a Clinical Review and Monitoring
Common Questions About Chronic Disease Management
What is chronic disease management?
It is ongoing nursing support for a long-term condition, between the appointments with your doctor. Monitoring, education, medication support, and a written plan for what to do when things change. The goal is fewer surprises and fewer hospital visits.
Which conditions do you cover?
Chronic heart failure, also known as congestive cardiac failure, chronic obstructive pulmonary disease, and diabetes. If your condition is not on that list, call us anyway and we will tell you honestly whether we are the right fit.
Will this replace my GP or specialist?
No, and it is not meant to. Your GP and specialist make the clinical decisions. Our nurses provide the regular contact in between and keep your treating team informed, which usually makes their appointments more useful rather than less necessary.
How often would I see a nurse?
Usually weekly to begin with, then less often as things settle. It depends on the condition, how recently you were diagnosed or discharged, and what else is going on. We review it regularly rather than locking in a schedule.
Can this be done by telehealth?
A good deal of it, yes. Education, plan reviews, and checking how the week has gone all work well by video or phone. Anything hands-on, a foot check or an inhaler technique review, is better done in person, so most people end up with a mix.
What happens if I get worse between visits?
Your written plan sets out exactly that: which signs mean call us, which mean call your GP today, and which mean call an ambulance. Knowing the difference is most of what the plan is for.
I already have a diabetes educator. Do I need this too?
Possibly not, and we will say so. Where you already have condition-specific support in place, our nurses can work alongside it rather than duplicate it, or step back entirely.
Renata Bell
OPTIMUM HEALTH SOLUTIONS
Renata is a Registered Nurse with extensive experience across disability, aged care, emergency, urgent care, community, primary health care and clinical governance. Renata has worked in various clinical settings in Australia and the UK and has a passion for Chronic and Complex Healthcare. She reviews all Nursing content for clinical accuracy and compliance.
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