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Chronic disease multidisciplinary care

Sub-acute Chronic Care Rehabilitation (SACCR)

Located in Rockhampton, SACCR is an interdisciplinary hospital avoidance and chronic disease management service for patients requiring > 2 disciplines.


Services are aligned with the SACCR Chronic Disease Model and include:

  • diabetes education
  • social work
  • occupational therapy
  • speech pathology
  • podiatry
  • dietetics
  • physiotherapy
  • exercise physiology
  • pulmonary rehabilitation
  • venous compression
  • nurse practitioners
  • clinical nurses
  • clinical scientist
  • pharmacist.


  • Aged > 18 years
  • Eligible for > 2 disciplines
  • Recent hospital admission (within 3 months), multiple re-admissions, or at high risk of hospital admission
  • Willing to participate
  • Has a diagnosed chronic disease which fits either diabetes, cardiac, respiratory, or venous compression criteria:


Type 1 or 2 diabetes with:

  • new diagnosis
  • recent (within last seven days) presentation to Emergency Department for diabetes related admission
  • major or problematic episodes of hypoglycaemia requiring additional assistance
  • acute diabetic feet
  • HbA1c ≥ 7%
  • unintentional weight change (change of ≥ 5% in past 6 months)
  • BMI < 8.5 kg/m2 or BMI > 30 kg/m2
  • gastroparesis
  • need for optimisation in the presence of severe vascular complications
  • unsatisfactorily-controlled diabetes with recent deterioration despite escalation of therapy (HbA1c 8 to 10%)


  • High risk for cardiovascular disease with inability to optimise 3 or more of the following risk factors:
  • Class II obesity – BMI > 30 kg/m2
  • Persistent hypertension – blood pressure > 140/90
  • Hypercholesterolemia – total cholesterol > 4 mmol/L or LDL > 2.5 mmol/L
  • Type 2 diabetes mellitus – Hba1C > 7%
  • Chronic kidney disease – eGFR < 45 mL/min/1.73 m2
  • Sedentary (< 150 minutes per week)
  • Clinically significant stress or depression


  • COPD
  • Chronic asthma
  • Interstitial lung disease (ILD)
  • Bronchiectasis
  • Chronic bronchitis
  • Pulmonary rehabilitation available to all respiratory patients, including those with:
    • cystic fibrosis.
    • pre- and post‑lung transplant surgery.
    • slow-to-recover pneumonia.
    • pulmonary arterial hypertension (PAH).
    • sarcoidosis.

Venous compression

  • Unmanageable lower limb venous oedema, with or without ulcer, at immediate risk of cellulitis and hospitalisation (interim support service only).
  • Medically appropriate/cleared for compression therapy before referral.


  • Nursing home patient
  • Patient has Department of Veterans' Affairs (DVA) Gold Card
  • Patient has current or unutilised General Practitioner Management Plan (GPMP)

Required information

Completed referral including the following information:

  • Current chronic disease diagnosis
  • Medication list
  • BMI
  • Smoking and alcohol and other drugs (AOD) status
  • Mental health status
  • Interpreter requirements
  • Hearing impairment

Standard information for all referrals

Reason for request

  • To establish a diagnosis
  • For treatment or intervention
  • For advice and management
  • For specialist to take over management
  • Reassurance for general practitioner or second opinion
  • For a specified test or investigation the general practitioner can't order, or the patient can't afford or access
  • Reassurance for the patient or family
  • For other reason (e.g., rapidly accelerating disease progression)
  • Clinical judgement indicates a referral for specialist review is necessary

Patient's demographic details

  • Full name (including aliases)
  • Date of birth
  • Residential and postal address
  • Phone contact numbers – home, mobile and alternative
  • Medicare number (where eligible)
  • Name of the parent or caregiver (if appropriate)
  • Preferred language and interpreter requirements
  • Identifies as Aboriginal and Torres Strait Islander Ask the patient their ethnicity

Referring practitioner details

  • Full name
  • Full address
  • Contact details – phone, fax, email
  • Provider number
  • Date of referral
  • Signature
  • Patient's usual general practitioner (if different from above)

Relevant clinical information about the condition

  • Inclusion of Clinical Prioritisation Criteria (CPC) where relevant
  • Presenting symptoms (evolution and duration)
  • Physical findings
  • Investigations carried out and results as indicated in the relevant pathway
  • Details of previous treatment (including systemic and topical medications prescribed) including the course and outcome of the treatment
  • Options already pursued
  • Body mass index (BMI)
  • Details of any associated medical conditions which may affect the condition or its treatment (e.g. diabetes), noting these must be stable and controlled prior to referral
  • Current medications and dosages
  • Drug allergies
  • Alcohol, tobacco and other drugs use

Clinical modifiers

  • Impact on employment
  • Impact on education
  • Impact on home
  • Impact on activities of daily living
  • Impact on ability to care for others
  • Impact on personal frailty or safety
  • Identifies as Aboriginal and Torres Strait Islander

Other relevant information

  • Willingness to have surgery (where surgery is a likely intervention)
  • Choice to be treated as a public or private patient
  • Compensable status (e.g., DVA, WorkCover, motor vehicle insurance)
Last updated: 30 January 2020

Refer your patient

Send the request form via
Fax: (07) 4932 5294

Service advice

Phone: (07) 4930 9009

CQUniversity Health Clinic
Berrill Lane
Rockhampton Campus
North Rockhampton, QLD 4700


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