Community Rehabilitation (Home and Centre based)

Pulmonary Rehabilitation is suitable for those who have lung disease or are limited by breathlessness. The program runs twice a week for 8 weeks. Each time you attend there is an education and exercise session. You will also be provided with a home exercise program. At the end of the Pulmonary Rehabilitation Program there may be an option to continue with a 6 week exercise program in a community fitness centre.

Specific eligibility criteria

Diagnosis of COPD residing in the Monash Health area (City of Casey, Greater Dandenong, Kingston or Monash, Bayside City Council or Shire of Cardinia).
Clients who do not live in the area but frequently use Monash Health respiratory services of emergency departments may also be eligible.

The service sees clients with all stages of COPD – from mild to severe.

Referrals

SACS Access and Intake
T: 13003 iCARE (1300 342 273) PRESS OPTION 5
F: 9554 9151
E: icareaccess@monashhealth.org

A referral will be required from your doctor, specialist or hospital. This should be forwarded to SACs Access and Intake along with copies of relevant tests completed in the last 12 months, for example:

• Chest X ray
• CT scan of chest
• Lung function tests
• Oxygen assessments

Enquiries

Pulmonary Rehabilitation Programs are located at 4 sites. For more information and enquiries, contact the site closest to you.

Clayton:

1 Tarella Road, Clayton
Tel: 9594 7630
Fax: 9594 7631
Email: claytoncrc@monashhealth.org

Springvale: (03) 8558 9158

55 Buckingham Avenue, Springvale
Tel: 8558 9158
Fax: 8558 9011
Email: springvalecrc@monashhealth.org

Cranbourne:

140–154 Sladen Street, Cranbourne
Tel: 5990 6114
Fax: 5990 6277
Email: cranbournecrc@monashhealth.org

Pakenham:

Henty Way, Pakenham
Tel: 5941 0500
Fax: 5941 0542
Email: pakenhamcrc@monashhealth.org

Cost

$50 for the complete program (8 weeks paid at the initial assessment) or $10 per session / $20 per week.
(Rebates cannot be claimed from any health insurance providers for any services received at our centres).

The Chronic Heart Failure (CHF) program provides support to GPs so they can manage their patient’s in the community. Clients diagnosed with CHF are referred from hospital, general practice or private cardiologists.

Successful CHF management involves enrolment in CHF management programs. The goal is to optimise CHF management, prevent hospital admissions and improve quality of life. Self management education is delivered by clinical nurse consultants. Clients are educated about CHF management, signs and symptoms of fluid retention, when to seek treatment and how to minimise exacerbations. This program recognises hospital admissions are a necessary part of the chronic illness. The program supports patients for 12 months, and then discharges them to the GP or private cardiologists.

Heart failure clinic review: Patient can be reviewed at the multidisciplinary CHF clinic over 12 months to ensure medications and treatments are optimised. This facilitates communication between the clinic and GP’s. Recommendations are made and sent to the GP. Ongoing follow up is done by phone or at home visits to support the client in self-management.

Psychological support: Clients can be referred to a CHF specialist psychologist.

Medication review and monitoring: Clients are reviewed by a CHF pharmacist at the clinic or in the home to support adherence and answer questions about the medication regimen.
Chronic Heart Failure Rehabilitation Program: A 10 week, CHF specific cardiac rehabilitation program facilitated by the CHF Physiotherapist at Casey and Dandenong Hospitals.

Exercise Maintenance Program: A supervised ten week exercise maintenance program held in local gyms to encourage ongoing exercise in the community.

Contact

Monday to Friday from 8:00am – 4:30pm

• Monash Medical Centre
• Dandenong Hospital
• Casey Hospital

Cost

There is no cost for the Chronic Heart Failure program, clinic or rehabilitation. The Exercise Maintenance Program charges a small fee for use of the Fitness Centre.

Eligibility criteria

• Diagnosis of Chronic Heart Failure
• Recent presentation or admission with LVF, APO or associated symptoms of Chronic Heart Failure
• Echocardiogram indicating heart failure
• Client is at high risk of presenting with exacerbation of symptoms of Chronic Heart Failure
• Medicare Card holder

Referral details

SACS Access and Intake

T: 1300 3 iCARE (1300 342 273) PRESS OPTION 5
F: 9554 8595
E: icareaccess@monashhealth.org

The journey of people with heart failure

Heart failure (HF) is associated with a high mortality and morbidity, reduced quality of life and increasing health care costs in Australia as well as across the world. The projected crude prevalence of HF is expected to increase significantly as the population ages.  People >65 years of age have a higher prevalence of all cardiovascular disease, and this population will grow significantly in the next two decades.

The rising trend in mortality and hospital admissions is likely to continue as the aging population grows. HF prognosis remains poor, often due to late diagnosis and inadequate management and support. 20-30% of people with mild to moderate heart failure will die within one year and 50% of people with severe heart failure will die within one year.

There is an expected 25% growth in prevalence of HF by 2030 compared to 2010; and to a doubling of the direct medical costs associated with HF. Within this context, HF constitutes a public health problem that has been characterised as an emerging epidemic by the World Health Organisation.

To understand the journey a person who has heart failure a study on the current state at Monash Health has been undertaken.

In addition over three years Monash Health Hospital Admission Risk Program has led a large scale systems reform for Heart Failure care. The system redesign has had a focus on responsiveness and demonstrating excellence in care delivery. Most significantly is the Complex Care response which links inpatient and ED patients with specialty community based Nurse Practitioner and Clinical Nurse Consultant care and support. This service has a focus on (where appropriate) early discharge and community follow up this includes Lasix titration in community and linkages with G.P. for continuity of care. The following system monitoring and controls have been put in place:

• Clinical risk screening discharged patients within 2/7days
• Clinical indicators to measure service delivery of best practice
• Peer audits of translating evidence to practice
• Protocol for deteriorating clients in community
• Feedback from patients in Appendix A clearly demonstrates people value this service delivery model