Clients referred to the Chronic Respiratory Disease stream are seen by a Respiratory Physician, Respiratory Nurse Consultant and a Physiotherapist as a means to supporting their GP to manage the client in the community.

Self management education is provided by the Respiratory Nurse Consultant usually at a home visit. The education seeks to enhance client knowledge and understanding about their condition, their medications and dosing/inhaler techniques, energy conservation and early recognition of symptoms of an exacerbation . A medication review is undertaken by the Nurse and where appropriate a referral to HOMR is completed

Other services provided include physiotherapy assessment, education and the implementation of an individualised physiotherapy program aimed at improving effectiveness of airway clearance and keeping the client as fit as possible. The physiotherapist can help the client to understand how their lungs work, how to and why they should exercise and how to do activities with less shortness of breath.

Respiratory review: Following acceptance on to the program, usually in the acute setting, clients are followed up in Chronic Respiratory Disease Clinic about 3 – 4 weeks after discharge from hospital where assessment is made by the Respiratory Physician, Respiratory Nurse Consultant, Physiotherapist and Psychologist (Dandenong).

Ongoing follow up: An initial home visit may be done by the Respiratory Nurse Consultant with a self management plan devised and further follow up is carried out via telephone, home visits or further clinic consultations.

Psychological needs are assessed and if necessary clients are referred to community psychologists or, if eligible, Care in Context psychological services. Pulmonary Rehabilitation Program referral is also completed.