N
NA
AV
VIIG
GA
ATTIIN
NG
G TTH
HE
EM
MA
AZZE
EC
CH
HE
EA
ATT S
SH
HE
EE
ETT
PPU
UR
RPPLLEE –– C
CR
RO
OSSSS BBO
OR
RD
DEER
R SSEER
RVVIIC
CEE,, BBLLU
UEE –– N
NSSW
WO
ON
NLLYY SSEER
RVVIIC
CEE,, G
GR
REEEEN
N –– VVIIC
CO
ON
NLLYY SSEER
RVVIIC
CEE
Chronic Disease Specific Services
SERVICE
TYPE
Intensive care
coordination
in chronic
disease
Chronic
Disease
Management
(CDM)
Programs
SERVICE
Mungabareena
Aboriginal
Corporation
Hospital
Admission Risk
ProgramChronic Disease
Management
(HARP-CDM)
ASET Program
Albury
Wodonga
Aboriginal
Health Service
(AWAHS)
MY HEALTH, MY
LIFE! Chronic
Disease Self
Management
Group Program
Cardiac
Rehabilitation
Albury
Diabetes
Program
Albury
Pulmonary
Rehabilitation
Albury
Cardiac
Rehabilitation
Wodonga
Diabetes
Program
Wodonga
Pulmonary
Rehabilitation
Wodonga
Support
Groups
Walkabout
group
Men’s Shed
Murray
Wheezers
Albury Wodonga
district Lung Net
Support Group
Heart Support
Australia Albury
Wodonga
Branch
Albury Wodonga
Diabetes
Support Group
Men’s Shed
DESCRIPTION OF SERVICE & TARGET GROUP
REFERRAL DETAILS
Aboriginal Health Promotion and Chronic Conditions (AHPACC) worker
provides support to Aboriginal clients with chronic condition/s and assists
in linking them with chronic disease services.
 (02) 6024 7599
Fax: (02) 60560376
Intensive care coordination and self management support for clients with
a chronic condition who are frequently admitted (or at risk of hospital
admission) due to a chronic disease (COPD, diabetes or heart failure)
Albury Wodonga Health Wodonga
e-referral:
www.connectingcare.com
 (02) 60517400
Fax: (02) 60517430
Albury Wodonga Health – Albury
 (02) 6058 4444
 (02) 6040 1200
Fax: (02) 6040 1222
Transport available & must be
booked in advance. Home visits
are available to clients unable to
attend the practice due to
medical conditions.
Albury Wodonga Health Wodonga
Mungabareena Aboriginal
Health Services
AWAHS
Albury Wodonga Health -Albury
(02) 60584561
Fax: (02) 60584520
Albury Community Health
 (02) 60 581800
Fax: (02) 6058 1801
Albury Wodonga Health -Albury
 (02) 60584515 Fax: (02)
60584710
Screening program for patients > 65 years admitted to Albury Hospital
through the A&E Dept. Follow-up via discharge planning
AWAHS provides Health Care Services to the Indigenous Community and
their immediate family, with a focus on preventative health care. Services
include: routine check ups, Adult Health Checks, family planning, Pap
smears, pregnancy tests, ECG: heart check, counseling, vaccinations,
minor surgery, stitching cuts, skin checks & removal of moles and
sunspots, nutritional advice and home visits. Hours: 9-5 Monday to
Friday, closed 12.30 – 1.30 for lunch
Four Session Chronic Disease Self Management Group Program, with 1:1
Health Coaching focusing on the participant’s individual health goal after
the program. Target group is any one with a chronic Disease (eg
Pulmonary disease, heart disease, diabetes, Parkinson’s Disease, Chronic
Arthritis) who would like to develop skills to manage their condition.
Option of individual or 10 week group program focusing on education and
self management. Health Professions involved include: Cardiac Nursing,
Physiotherapy, Occupational Therapy, Social Work and Dietetics.
Individual or group programs available for clients with pre-diabetes, type
1 or type 2 diabetes and gestational diabetes.
Option of individual or group program focusing on education & self
management. Health Professionals involved- Cardiac Nursing,
Physiotherapy, Occupational Therapy, Social Work, Speech Pathology and
Dietetics.
Option of individual or group program focusing on education and self
management, for clients who have had an acute cardiac event. Health
Professionals involved include: Cardiac Nursing, Physiotherapy,
Occupational Therapy, Social Work and Dietetics.
Individual or group programs available for clients with pre-diabetes, type
1 or type 2 diabetes and gestational diabetes. Health Professionals
involved include: Diabetes Education, Dietetics, Podiatry, Physiotherapy
and Pharmacy.
Option of individual or group program focusing on education & self
management. Health Professionals involved include: Cardiac Nursing,
Physiotherapy, Occupational Therapy, Social Work, Speech Pathology and
Dietetics.
Aboriginal Lands Council Walking Group
Gathering place for men to undertake activities of interest.
Support group for people with COPD and other respiratory Illnesses.
Non-profit organization associated with the Australian Lung Foundation
Meets third Thursday of the month at Glenecho Neighbourhood House
1.30 – 3.30 pm
Support group for heart patients & their families. Provides: free of charge
support to patients and their families (not conditional upon membership),
regular newsletters & information, social, recreational & educational
activities, provides assistance to rehabilitation programs.
Meet every Thursday 8am at Albury Sports Stadium for 45min walk
Support Group for people with type 1 or type 2 diabetes, or at risk of
diabetes & their families. Run through Diabetes Australia NSW/Vic, it
provides up to date information & guest speakers at the meetings, local
newsletter and opportunities to meet others with diabetes.
Gathering place for men to undertake activities of interest.
Emerald House, Emerald Ave, Wodonga  (02) 6059 3639
Albury Wodonga Health –
Wodonga
e-referral:
www.connectingcare.com
 (02) 60517400
Fax: (02) 60517430
Albury Wodonga Aboriginal
Health Service (AWAHS)
 (02) 6040 1200
Fax: (02) 6040 1222
Albury Wodonga Health- Albury
COPD Rehab Program (02)
60584515
 (02) 60 569966
(02) 60214939
 1300725755 (for the cost of a
local call) or
 (02) 60432845 Ordinary
Membership $11, Associate
Membership $5.50
Regular Meetings at the
Commercial Club Albury.
 (02) 60 431125 (AH)
 (02) 60 218668
Manual Activities Centre, Nowland Ave, Lavington  (02) 6025 5440
N
NA
AV
VIIG
GA
ATTIIN
NG
G TTH
HE
EM
MA
AZZE
EC
CH
HE
EA
ATT S
SH
HE
EE
ETT
Public Dental
Services
AWAHS
Albury Community
Health Dental
Serrvices
Wodonga Public
Dental Services
Medicare
Dental Items
Medicare chronic
disease dental
scheme
Dental services available
 (02) 6040100
Fax: (02) 6040 1222
Free oral health care to NSW residents who hold a current NSW Health Care Card
or other recognised concession card (DVA, Pensioner, etc). All Children are eligible
for free oral health services until the age of 18yrs. All patients are assigned a
priority code after completing a phone survey. Those with high priority oral health
needs will be given prioritised appointments.
Public dental service are available for Victorian concession card holders and their
dependants, school age children from year 9 upwards with parents on a Pensioner
Concession Card or Health Care Card and all pre school and school age children. A
co-payment of $28 exists where parents do not hold a concession card. CoPayment of $23 -$92 exists for adult patients per course of care. All emergency
treatment enquiries are triaged and waiting lists applies. Co-Payment exemptions
exist in some circumstances.
Clients with a chronic condition and complex needs may be eligible for a Medicare
rebate (under a GPMP and TCA) for dental services if their oral health is impacting
on, or likely to impact on their general health however this service is not provided
by public dental services and must be arranged via a general practitioner.
Albury Community Health
 1800 450 046
Fax (02) 6058 1801
 1300 360 054 (for the cost of a
local call)
Or (02) 6051 7925
Services are based at Gateway
Community Health
Visit:
http://www.medicareaustralia.gov.au
/provider/medicare/initiatives/
Other services for clients with chronic and complex conditions
Home and
Community
Care Services
Department of
Aging Disability
and Home Care
(DADHC)
Age Concern
Albury Wodonga
Inc
Meals on Wheels
Mercy Health
Mungabareena
Aboriginal
Corporation
Rumbalara
Palliative
Care
Counseling
and Support
Services
Palliative Care
Mercy Health
The following services are available:
- Assessment for HACC Eligibility/support required
- Home care-shopping, cooking, cleaning.
- Personal Care-showers, therapy programs, exercise programs
- Respite Care
The following services are available:
- Community visitor scheme
- Centre based Day Care
- Social Support and Community Development
- Home modification and maintenance
Albury residents
The following services are available:
- Geriatrician
- Community Therapy Unit- no falls, Physiotherapy Outpatient program,
- Occupational Therapy Services- can self refer of GP referral, no cost (HACC Clients)
- Transitional Care Program (20 beds)
- Geriatric Assessment Unit (20 beds) slow stream rehab, overseen by Geriatrician.
- Healthy Aging Unit
- NSW ACAT Team (6042 1406)
HACC Worker provides culturally appropriate support to HACC eligible Aboriginal
clients and their careers and assists in linking them with chronic disease services.
Health Worker organizes and provides culturally appropriate support and assistance
to Aboriginal clients with respect to their health needs.
Community Controlled Aboriginal Health Service, services include a medical centre,
diabetes program, Women’s health program. Aged Care
Inpatient (10 beds) and outpatient services available. Also provides support with
aids and equipment to eligible clients. GP referral required.
 1300881144 (rural clients)
 1800 052 222
Aboriginal Home Care Service
 (02) 60 215 122
www.ageconcern.org.au
 (02) 60412004
Fax: (02) 6041 2004
 (02) 6042 1400
Fax: (02) 60214378
 (02) 6024 7599
Fax: (02) 60560376
 (03)58222866
Fax: (03) 58313549
 (02) 60421410
Fax: (02) 60213156
Community Palliative Care
 (02) 6042 1461
Albury Wodonga Health - Wodonga
Hospital
e-referral: www.connectingcare.com
 (02) 60517424
Fax: (02) 60517427
Health Albury
Wodonga Health Wodonga Hospital
Service for individuals living with a life threatening illness. The service provides
advice & assistance to manage distressing symptoms eg pain, nausea & vomiting,
assists in coordinating support services, provides emotional support to families,
specialised equipment loans and grief and bereavement support.
Albury Community
Health
Mental health, generalist and drug and alcohol counseling available. Home detox
and sexual health services also available.
Albury Community Health
 (02) 60 581800
Fax: (02) 60581801
Gateway Health
A wide range of support and counseling services, including specialists services for
issues including drug and alcohol issues, domestic violence, grief and loss,
relationship education and gamblers help . All ages. Get Together House is a
psychosocial rehabilitation day program for clients aged 16 – 64 with a mental illness
or psychiatric disability. See: www.uhchs.vic.gov.au
Counseling over the telephone. 24 Hour Line
Information and Support.
Professional Health Advice
Counseling for Carers
Aboriginal Spiritual and Emotional Wellbeing Worker- Mental Health Services
provides culturally appropriate support for Aboriginal clients with mental health
issues and illness and their carers.
Gateway Community Health
e-referral: www.connectingcare.com
 (02) 60228888 Fax: (02) 60245792
Referral on SCTT preferred.
LifeLine
Men’s Line
Nurse on Call
Carers Australia
Albury
Wodonga Health Wodonga Hospital
 131114
 1300 7889978
 1800 606 024
 1800 242 636
 0418 590 354
N
NA
AV
VIIG
GA
ATTIIN
NG
G TTH
HE
EM
MA
AZZE
EC
CH
HE
EA
ATT S
SH
HE
EE
ETT
Visiting
Nursing
Services
Albury Community
Health
Albury Wodonga
Health Wodonga
Campus
District Nursing
Service
Beltana Nursing
Services
PNR
Royal District
Nursing Services
(RDNS)
NGM Home
Nursing
Case
Management
/ Care
packages
Community
Options (COPS)
Albury and District
Compacs Albury
and District
Woodstock
Support Inc
Rumbalara
Aboriginal Co
Operative LtdCACP
UPA Murray River
Region Aged Care
Services
Community
Support North East
Upper Murray
Family Care
Community
Interlink
Advocacy
AWAHS
Home and centre based nursing service providing nursing care, support, health
education, referral assessment. Saturday & Sunday only essential services available.
Wound care, medication assistance/education and post acute care
Services available to anyone requiring home based nursing care and include: wound
care, medication management, assessment and monitoring of health status including
blood pressure and assistance with diabetes management, palliative care, coordination of care with other health service providers and continence management.
Provide personal care, dressings, IV anti-B's, injections, short and long term care,
supervision medications, nursing care, palliative care, general nursing care.
Home and community care provider employing personal carers, Div 1 and 2 nurses.
Services include personal care, social outing, dressings, medication dispensing,
health assessment and monitoring.
Home based nursing service. Services include: personal care, dressings, medication
dispensing, monitoring, including blood pressure. Current Providers for Department
of Veteran’s Affairs.
Home based nursing service. Services include: personal care, dressings, medication
dispensing, monitoring, including blood pressure. Current Providers for Department
of Veteran’s Affairs.
Community Options provides individual case management and may arrange or assist
with the provision of services for frail-aged, people with disabilities and their carers
( 02) 6058 1820
Fax (02) 6058 1801
 (02) 6051740 Fax: (02) 60517404
Fees are set by the Department of
Human Services, however no one will
be refused service if they are not able
to pay
 (02) 6022 4166
Fax (02) 6022 4579
Mon-Sun 8am-2pm
 (02) 60568939
fax: (02) 6056 9125
Fee applies.
1300 334455 24 hours phone
service for referrals
Fax: 1300 657 265
 and Fax (02) 60255455
7 days a week incl. public holidays.
 (02) 60513983
Fax: (02) 60231322
Provide case managed package for up to 6 weeks after discharge from hospital. This
service is for people who need ≥ 2 services in order for them to return home safely
Services include; Case Management, Domestic Assistance, Personal Care, Meals,
Social Support, Transport, Respite Care, Small items of equipment and Home
Modification and Maintenance.
Woodstock Support Inc provides planned respite care for carers of frail and aged and
people with a disability through a range of programs and services.
Community Aged Care Packages (CACP), Extended Aged Care (EACH) and Extended
Aged Care Dementia (EACHD) provides a package of care support services provided
at the clients home as an alternative to relocating to low or high level residential
aged care. Support may include Personal care, Domestic Assistance, Shopping,
Transport, Meals, Nursing Care and Respite. Hours of support are determined with
client at assessment. Rumbalara Aged Care has funding to provide 5 CACP, 4 EACH
and 4 EACHD for Aboriginal, TSI and their partners from 50 years
UPA provides a variety of aged care services including 25 Community Care Packages
and a range of residential options.
 (02) 6051 3983
Fax (02) 6023 1322
A ranges of care packages, including short term packages, for aged clients and
people with a disability are available. Fee for Service Case management also
available.
Case management options (e.g. disability >65 years, funding packages from
Department of Health for complex clients, CAPS packages), Carer support including
respite, information, support and activities for carers. They can also arrange
additional support on discharge from hospital.
Provides a range of Care Packages including CAPS, Linkage (>65 yrs with disability),
EACH and EACH dementia packages, short term funding for clients <65 years, ABI
team, ABI short term case management, National Respite for Carers Program, Early
Childhood case management.
Legal advice service available once a week
 (02) 6055 3400
fax: (02) 6056 8512
e-referral: www.connectingcare.com
(02) 6022 800 Fax: 60228099
e-referral: www.connectingcare.com
(02) 60 584000
Fax (02) 60584050
 (02) 60 25 1226
Fax: (02) 6025 1277
 (02) 60251776
Fax (02) 6025 5712
 1800 222 582
 (02) 6042 1200
 1800 421 640
Respite Care
Disability Advocacy Individual and systemic advocacy, community education, training and support group
and Information
development. See: www.disability-advocacy.com.au
Service (DAIS)
Carer Respite Centre Riverina Murray
Community Options /Dementia Respite Options
Southern Cross Apartments
Uniting Care (Day and Weekend Respite)
Ameroo Dementia Day Club
Twilight Dementia Day Club
Lutheran Day Respite
Uniting Care
Overnight, day and evening respite care- McFarlane House, 11A McFarlane Road,
Goulburn NE
Wodonga, 3690
Upper Murray
Provide Carer Support including respite.
Family Care
 (02) 6056 2420
 1800 052 222
 (02) 6051 3983
 (02) 6040 8844
 (03) 5723 8000
(02) 6025 1776
(02) 6021 7726
(02) 6042 1140
 (02) 6024 6078
(02) 6022 800 Fax: 60228099
e-referral: www.connectingcare.com
This resource was produced by the Upper Hume Primary Care Partnership
Albury Wodonga Chronic Disease Working Party. For any
additions/amendments, please call (02) 60527406 and update your copy.
Further information on services can be found at:
www.humanservicesdirectory.vic.gov.au or www.connectingcare.com