Engaging community health nurses to facilitate a telehealth chronic disease model of care

Carolyn Bourke1

1 Telehealth Service, Darling Downs Hospital & Health Service, Mt Lofty Nursing Home, Rifle Range Road, Toowoomba, 4350 carolyn.bourke@health.qld.gov.au



In the smaller rural hospitals of the Darling Downs Hospital & Health Service there is decreased capacity for the rural nurse generalist to facilitate telehealth appointments due to the minimum staffing. In these sites there is usually a Registered Nurse, Enrolled Nurse and the Director of Nursing, therefore the assistance of the Community Health Nurse has provided a solution to more care locally and has created a strong link to primary health care and the management of chronic disease patients in their hometown.  The role of the rural community health nurse is diverse and dependent on the needs of the local community; it creates the perfect synergy for being the link between the patient, their GP and the specialists for the management of chronic disease. Telehealth is the vehicle for evidenced based care in collaboration with the health care team and the value of supporting patients at home should not be under estimated.


Current Community Health nurse practices in our facilities include undertaking in daily inpatient ward round to assist in discharge planning and ensuring patients have supports systems in place. Post discharge telephone calls have been introduced which enhances patient recovery and provides a hospital avoidance strategy. The community health nurse aims to maximise the independence of people in their homes and assist in care coordination in collaboration with the GP. Our community health nurses are routinely participating in more 29 speciality telehealth clinics in the HHS.


Community health nurses report very positive feedback from their participation in telehealth clinics which includes increased knowledge of chronic conditions which provides an understanding of patient needs as they build trusting relationships with consumers and improve their general wellbeing.

The DDHHS has been successful in obtaining funding for 3 CNC Chronic Disease Nurse Navigators to commence next year.


This presentation will focus on the current role of the community health nurse and the emerging need to develop a Telehealth Chronic Disease Model to achieve integration of care working in partnerships to reduce rates of complication and extended hospitalisation.

The future will include more telehealth monitoring in the home and participation in speciality telehealth clinics including Diabetes, Cardiac, Cancer and End of Life care.

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