Community health and aged care services referrals

A wide range of community-based services are available at West Moreton Health which GPs can refer into to support the care management of their patients.

Aged Care Assessment Team

Service information

The Aged Care Assessment Team (ACAT) comprehensively assesses the care needs of older people who have complex care needs that cannot be met by Home and Community Care (HACC) services. This helps them know what their options are and choose the help that best meets their needs.

We look at the whole person—what they can do for themselves and what they need help with—as well as their health care and social needs.

When is an ACAT assessment needed?

Assessments are needed to access:

  • 'packaged' community care at home
  • subsidised residential aged care and respite care.


People requiring any of the above services who are:

  • over 65 years of age; or
  • over 50 and Indigenous; and
  • who are no longer able to manage at home without assistance.

Young people with a disability may be assessed in some circumstances.

Referral pathway

Referrals by family or carers

  • Phone My Aged Care on 1800 200 422.

Referrals by GPs and other providers

Residential Aged Care Acute Support Services

Service information

The Residential Aged Care Acute Support Services (RaSS) model provides care in partnership with GPs and RACFs to improve patient choice of care setting and the quality and safety of care provided across the care continuum.

The RaSS is a single point of contact for RACF staff and GPs with residents who have acute health care needs beyond existing capabilities. When needed, experienced clinicians are available to provide:

  • telephone triage – telephone assessment of acute care needs and matching the care need to the most appropriate care delivery service
  • ED substitutive care – acute assessment or care in the RACF environment as an alternative to ED transfer; the types of care able to be delivered will be determined by the scope of practice of individual RaSS staffing models
  • gerontic nursing assessment for RACF residents presenting to ED or admitted to hospital
  • discharge planning, co-ordination and transitional communication for RACF residents presenting to ED or with an acute admission, including for residents who have presented to and been discharged from ED after-hours
  • follow-up of all RACF residents at 7 days (earlier if clinical need requires) to ensure fulfillment of referrals, resolution of care need
  • specialist consultative services for RACF residents via telehealth or in-person visits (where resources allow).


Patient must be living in a Residential Aged Care Facility governed by the Aged Care Act 1997.

Referral pathway

Phone call to telephone triage line: 07 3810 1530.

Contact information

Bowel Screen

Service information

The National Bowel Cancer Screening Program (NBCSP) invites Australians aged 50-74 years to screen for bowel cancer using a free, simple test at home. Australia has one of the highest rates of bowel cancer in the world. Around one in 23 Australians will develop bowel cancer during their lifetime. The NBCSP aims to continue to reduce deaths from bowel cancer through early detection of the disease.

Role of the GP

For your patients, you are asked to:

  • encourage those who are sent a screening test and for whom the test is clinically relevant, to participate
  • assess those with a positive result and refer them for further examination as clinically indicated, for example a colonoscopy
  • indicate whether a patient referred for colonoscopy is a program participant to assist with reporting to the Program Register (program stickers are available by calling the information line on 1800 118 868)
  • notify the Program Register of referral/non referral for colonoscopy or other bowel examination for participants with a positive result - this can be done by returning the program’s GP Assessment Form by fax or post (provision of information will attract a payment)
  • manage individuals identified as being at increased risk of bowel cancer in accordance with the National Health and Medical Research Council (NHMRC) Guidelines
  • inform individuals at average risk that the NHMRC Guidelines recommend screening at least once every two years from the age of 50 to 74 years of age
  • To refer a patient to Ipswich Hospital for a colonoscopy due to a positive FOBT result for the NBCSP please fax the referral to the Ipswich General Hospital Priority Referral Number – (07) 3413 7277
  • If you have any enquiries regarding your patient’s referral please contact (07) 3413 7816 – Endoscopy Coordinator.

The Royal Australian College of General Practitioners (RACGP) provides clinical guidelines for bowel cancer screening on its website.

Provision of information will attract a payment.

Contact information

  • Bowel Screen Information Line: 1800 118 868
  • Ipswich Hospital Priority Referral Number: (07) 3413 7277
  • Endoscopy Coordinator: (07) 3413 7816

Service information

BreastScreen Australia is the national breast cancer screening program. It invites women aged between 50 and 74 for a free mammogram every two years. BreastScreen Australia aims to continue to reduce deaths from breast cancer through early detection of the disease. No GP referral is required.

Community HealthPathways

Log in to the Community HealthPathways


  • BreastScreen Queensland recommends and actively encourages women aged 50 to 74 years to have a breast screen every two years as the evidence of the benefits of regular breast screens are strongest in this age group.
  • Women in their 40s and 75 years and over are also eligible to have a breast screen with BreastScreen Queensland, if they choose, but are not actively encouraged to screen. This is because the evidence of benefits is less clear in these age groups. It is recommended that women in their 40s and 75 years and over talk to their doctor about whether breast screening is right for them.
  • Women under 40 years are not eligible, because:
    • women in this age group are at a much lower risk of developing breast cancer;
    • there is no current evidence that breast screening is effective in detecting early stages of breast cancer in this age group; and
    • younger women tend to have denser breast tissue which makes it more difficult to see breast cancers on breast screen images. Breast cancers and dense breast tissue both appear white on an image, making it more difficult to detect breast cancers.

Contact information

To make an appointment:

Out of hours and Saturday appointments available upon request.

More information at breast screening page.

Chronic Conditions - Cardiac Rehabilitation Service

Service information

Cardiac Rehabilitation is the best treatment to assist patients in recovering from a heart attack, angioplasty/stent procedure or bypass surgery. Cardiac Rehabilitation is also very helpful for patients with angina or heart failure.

Cardiac Rehabilitation consists of:

  • initial interview and assessment of current condition and risk factors for heart disease
  • individualised exercise program to suit patients’ needs
  • information sessions for patients and family members
  • access to lending library - video, DVDs and books.


The following diagnoses are considered as criteria for inclusion for Cardiac Rehab assessment/program commencement.

  • Stable Angina
  • ACS
  • CAD for medical management
  • PCI
  • CABG
  • Valvular surgery
  • Takotsubo cardiomyopathy
  • SCAD.

Referral pathways

Smart Referrals is the preferable choice for GP referrals.

Contact information

Ipswich Cardiac Rehabilitation Service

Chronic Conditions - Diabetes Service

Service information

The Ipswich Diabetes Service aims to provide a comprehensive service for people with Diabetes in partnership with the General practitioner. The multidisciplinary team includes Physicians, Endocrinologist, Diabetes Educators and Allied Health.


People with T1DM and T2DM above 16 years of age.

Referral pathway

There is no set referral form - fax all referrals to the central intake unit 3810 1438.

Please include the following with the referral:

  • a GP referral addressed to either:
    • Dr Nathow
    • Dr Dover
    • Dr Min
    • Dr McKean
  • client contact details (name / DOB / address / telephone number)
  • GP contact details (name / address / telephone and fax number)
  • indicate if interpreter required (Yes/No) and language
  • reason for referral.

Please ensure the following information is included:

  • HbA1c (current and previous)
  • medical history
  • E/LFTs, FBG, eGFR, FBC, TFTs, current medication list
  • Full lipid profile
  • eye screen report - optometrist (optional)
  • urinary albumin excretion (ACR)
  • list of other health professionals involved in care.

Contact information

Ipswich Diabetes Service

  • Phone (07) 3813 6150
Chronic Conditions - Heart Failure Service

Service information

The Heart Failure Service aims to provide evidence-based, timely and quality care, utilising a multidisciplinary approach to heart failure patients in the West Moreton region that enhances their quality of life and reduces hospitalisations at every stage of their disease process.


Referral criteria

All persons over the age of 16 years with symptoms of heart failure, regardless of aetiology, should be considered for enrolment if there is a confirmed diagnosis of:

  • heart failure with
    • reduced ejections fraction (HFrEF)
    • preserved ejection fraction (HFpEF)
    • associated valvular disease or isolated right heart failure (e.g. cor-pulmonale).

Referral pathway

Referrals are accepted through the wm-refer portal.

Chronic Conditions - Lung Health Service

Service information

The Lung Health Team takes a holistic, patient-centred, lifespan approach to the provision of services for patients with respiratory disease. It builds on the knowledge, best practice, service delivery models and capacity of existing programs and services to support patient self-management through:

  • providing services in a timely fashion – all referred patients are contacted within 7-14 days following hospital discharge.
  • optimising the quality use of respiratory inhalers and medications according to the current evidence and national guidelines while encouraging the use of management plans to support self-management.
  • implementing referral to the pulmonary rehabilitation service to improve patient outcomes. If referring to pulmonary rehabilitation, please provide up to date spirometry as part of the referral information.
  • identification of Lung Health patients with anxiety, depression and reduced coping skills and provide psychological interventions that will improve these.

To assist in the education of health professionals within the hospital, community and primary care settings.

Case manage patients in the community with respiratory disorders in collaboration with the patient’s general practitioner. Case management can occur through home visits, face-to-face appointments,  virtual and telehealth.

The Lung Health team consists of a nurse practitioner, clinical nurse consultant, clinical nurses, registered nurses, exercise physiologists and supported by allied health professionals including dietitians, social workers, psychologists, exercise physiologist and occupational therapists.


Any patient with a diagnosis of asthma, chronic obstructive pulmonary disease (COPD), bronchiectasis, interstitial lung disease or pulmonary fibrosis. The lung health service does not cover lung cancer diagnosis. The service is for those over 16 years of age and does not provide spirometry for the purposes of diagnosis.

Referral pathway

Referral to the lung health team is for nurse case management, if patients require review by a respiratory consultant this should be completed through existing West Moreton referral pathways.

Contact information

Lung Health Team

  • Phone: (07) 3447 2870


  • Clinics: Jaghu Gym, Ground Floor, Hayden Centre, 37 South Street, Ipswich
  • Outpatient clinics: Level 6, Ipswich Hospital, Chelmsford Avenue, Ipswich
Community Based Rehabilitation Team

Service information

The Community Based Rehabilitation Team is an outpatient rehabilitation service (centre-based) which aims to deliver high quality multidisciplinary care to improve client participation in home-based and community activities. The service delivers a holistic model of restorative and/or adaptive therapy that is focused on the clients individual goals.

It aims to:

  • help clients met their rehabilitation goals within a timeframe
  • improve and empower participation in self-care and community activities
  • assist clients to work towards self-management of your health condition.

A mix of services will be offered to meet individual needs, including individual and/or group therapy. The team includes:

  • Occupational Therapy
  • Physiotherapy
  • Speech Pathology
  • Social Work
  • Psychology
  • Clinical Nurse
  • Rehabilitation Physician
  • Allied Health Assistant.


  • Consent to receive the service
  • Be over 18 years of age
  • Have rehabilitation goals that are achievable and focused on improving your independence at home or in the community following a recent medical event.

Referral pathways

CBRT referral form (PDF) to be sent to West Moreton Health CRU.

Contact information

Community Based Rehabilitation Team

  • Phone: 3813 6160
  • Location: Lower Ground Floor, Ipswich Health Plaza, 21 Bell Street, Ipswich
Child Development Service

Service information

The Child Development Service is a multidisciplinary team that works with families, communities and professionals to understand the needs of children and young people who have developmental problems. It is a free public health service based at Goodna Community Health Centre and Ipswich Health Plaza. The service provides multidisciplinary diagnostic assessment to gain a deeper understanding a child’s developmental strengths and difficulties.


Infants, children and adolescents (0–18 years)

  • Children are eligible to access services if they have moderate developmental delay in two or more domains (functional areas) and require input from two or more allied health therapists for diagnostic assessment and formulation:
    • posture and large movements
    • fine motor/visual motor
    • communication (receptive and expressive)
    • cognition and learning
    • social behaviour/play
    • adaptive (feeding, sleeping, regulation and sensory organisation).
  • In line with other West Moreton Health services, referrals will be accepted until a child's 16th birthday and children are eligible for assessment until their 18th birthday.

Ineligible referrals

  • Universal service requests, such as developmental monitoring or screening
  • Questions or concerns not of a developmental or behavioural nature.
  • Allied Health intervention beyond the assessment, diagnostic process and brief intervention – long term therapy is not provided by this service.
  • The child referred has been seen by West Moreton Health Child Development Service within the last 12 months without any change in presenting concerns/psychosocial risk factors.
  • Children with single functional domain delays.

Referral pathway

We accept referrals for children up to 16 years of age, who reside within the West Moreton Health catchment area. This catchment area includes Ipswich, Gatton, Springfield, Ripley, Laidley, Boonah and Esk.

GPs can make a referral to West Moreton Child Development Service via Smart Referrals to Specialty Paediatrics.

Contact information

Ipswich Health Plaza

  • Phone: 07 3817 2444

Goodna Community Health

  • Phone: 07 3818 4800
Hospital in the Home

Visit the virtual care, share care and HITH referrals page to access Hospital in the Home information.

Preventative Integrated Care Service

Service information

The Preventative Integrated Care Service (PICS) provides rapid access (review within 24-48 hours) to intensive specialised medical management and multidisciplinary support for patients with diabetes, cardiac or respiratory chronic conditions, in order to avoid a future preventable hospital presentation or admission. The multi-disciplinary team will be led by a Clinical Director, with Senior Medical Officers from respiratory, cardiology and diabetes, nursing (including Nurse Practitioners), social work, physiotherapy, occupational therapy, dietetics, psychology, podiatry, and pharmacy staff. Together, the team work to improve patient health through rapid access to care, identifying and addressing risk factors for hospital presentation, and by supporting people to self-manage their condition.

Patients are able to access care via outpatient clinic appointments, telephone and telehealth appointments, and via home visits. The Service provides care over a period of 16 days, with an aim to stabilise the patient prior to on-referral to an appropriate service or back to primary care.


Worsening symptoms related to a chronic condition in the primary care environment requiring escalation of management and multidisciplinary support to avoid a future presentation to hospital.
Post-discharge from a complex respiratory, cardiac, or diabetes-related hospital admission.

Please note: PICS is not an emergency service and is not to replace higher acuity services, such as the Emergency Department or HITH.

Patient is known to West Moreton Health:

  • Presentation to hospital for the same condition in the past 2 years, or
  • Assessment by a specialist for the same condition in the past 2 years, or
  • Patient has an active referral for the same condition awaiting review in Specialist Outpatient Department, or
  • Patient has an active referral to an existing WMH service for the same condition.

Respiratory (16 years of age or older)

  • Asthma
  • Chronic obstructive pulmonary disease (COPD)
  • Bronchiectasis, or
  • Interstitial lung disease

Cardiac (18 years of age or older)

  • Heart failure
  • Cardiovascular disease

Diabetes (16 years of age or older)

  • HbA1c ≥10%
  • Unstable diabetes requiring insulin
  • Steroid-induced diabetes requiring rapid assessment
  • Acute diabetic foot / wound:
    • Foot ulcer or pressure injury with mild to moderate infection < 2cm around wound
    • Necrosis/dry gangrene (with or without ulceration)
  • Diabetes requiring optimisation in the presence of severe vascular complications e.g. Stage >3 CKD, proliferative retinopathy, gastroparesis
  • Acute deterioration of glucose levels in a patient on dialysis (haemodialysis and peritoneal dialysis)
  • Recent Emergency Department presentation or hospital admission for one of the following:
    • severe hypoglycaemia, or
    • diabetic ketoacidosis (DKA), or
    • hyperosmolarity hyperglycaemic state (HHS)


Exclusions (concerning features requiring higher acuity care):

  • Hemodynamically unstable
    • Resp Rate > 30
    • Tachycardia > 120
    • Systolic BP < 90 mmHg
  • Associated with severe breathlessness (i.e., NYHA Class IV)
  • Signs of acute pulmonary oedema
  • Severe, ongoing angina
  • Dynamic ECG changes including
    • new left bundle branch block
    • ST elevation or depression
    • high grade heart block
  • Syncope/Presyncope

Referral pathway

Phone: (07) 3447 2744

Fax: (07) 3447 2893 (pending E-fax system)

Contact information

Hours: 8 am-4 pm, Monday-Friday

Please see HealthPathways for the most up to date contact details.

Public Health Unit

Service information

The West Moreton Public Health Unit undertakes the following activities across the region:

  • Undertake epidemiology activities including collating, analysing, monitoring and disseminating information on health status and disease trends.
  • Coordinate disease control initiatives across the Area, including response to and notification of disease outbreaks.
  • Monitor and enforce public health legislation and policies including emergency management, environmental toxicology, food safety, regulated drugs and poisons and tobacco control.
  • Collaboratively plan, implement and evaluate population health programs and projects including injury prevention and safety promotion, physical activity, public health nutrition and mental health promotion.

Contact information

  • Phone: (07) 3818 4700
  • Location: Goodna Community Health, 81 Queen Street, Goodna, Queensland, 4300
Sexual Health and Blood Borne Virus Service

Service information

The Sexual Health and Blood Borne Virus (BBV) service is staffed by a multidisciplinary sexual health team which works to ensure a pro-active public health response in the areas of sexually transmitted infection, HIV AIDS and Hepatitis C.

Referral pathway

A referral is not required for most services.

Call for appointment.

Contact information

  • Phone: 07 3817 2428
  • Email:
  • Hours: 8 am-4 pm, Monday to Friday
  • Location: Ground Floor, Ipswich Health Plaza, 21 Bell Street Ipswich Queensland 4305
Western Corridor Pulmonary Telerehabilitation

Service information

The Western Corridor Pulmonary Telerehabilitation is an innovative hub and spoke model of care to improve access to pulmonary rehabilitation. Pulmonary rehabilitation has been demonstrated as an essential component in improving self-management, symptom management, health outcomes and preventing avoidable hospitalisations for those living with chronic respiratory disease.

Western Corridor Pulmonary Telerehabilitation delivers care closer to home for patients that have limited or no access to pulmonary rehabilitation at their local health facility. It is delivered in collaboration with West Moreton Health; Darling Downs Health; and South West Hospital and Health Service, and complements and supports the current pulmonary rehabilitation services within these regions that are located at Ipswich, Toowoomba, Roma and St George.

Telerehabilitation has been demonstrated to be safe, convenient, patient preferred and decreases barriers such as travel, parking and cost.

The hub is located within Ipswich (West Moreton Health) and is staffed with highly skilled and experienced respiratory nurses and exercise specialists.

Spoke site clinicians and services, within the three Hospital and Health Services, share the care of the patient. All in person pre- and post-assessments are completed at your local health facility.

Pulmonary rehabilitation is a program of supervised and individualised exercise and education to help your recovery post flare up or hospitalisation to be more active and independent.

Programs generally run for eight weeks with one-to-two sessions per week. A flexible patient centred program is offered with classes every day.


  • Confirmed respiratory diagnosis:
    • chronic obstructive pulmonary disease (COPD)
    • asthma
    • bronchiectasis
    • pulmonary fibrosis
    • interstitial lung disease
    • pulmonary hypertension, or other chronic respiratory conditions
  • Willing and able to participate in a progressive exercise program for eight weeks
  • Age over 18 years
  • Consents to participate
  • Living within West Moreton Health, Darling Downs Health or South West Hospital and Health Service catchments
  • Independently mobile with or without aid
  • Access to a device (Mobile, laptop, computer or tablet) with camera and microphone
  • Able to operate device and equipment with support or have a support person available
  • Confirmation of suitability and safety to participate in program from medical team
  • Willing to comply with an agreed safety plan that supports a safe exercise environment and details steps to be taken in the case of an emergency.

Referral pathway

Referral to the Western Corridor Pulmonary Telerehabilitation is not for respiratory nursing or specialist respiratory services. If a patient requires review by a respiratory consultant or nursing case management this should be completed through existing West Moreton Health referral pathways.

Contact information

Western Corridor Pulmonary Telerehabilitation Clinical Team