For East Gippsland resident Nicole, an encounter with Bairnsdale Regional Health Service Complex Care Nurse Consultant Kate Smith was life-changing.

Nicole’s health had deteriorated since moving to our region. She consulted her Melbourne GP via phone but had no GP in Gippsland.

She became badly overweight, retaining a great deal of fluid, which caused other medical issues including fluid retention, asthma, shortness of breath and pain – even just by standing.

“I could hardly walk pain-wise and with my shortness of breath. I couldn’t do anything. I had a GP in Melbourne but because I was seeing her on the phone, she couldn’t see that I was putting on a lot of weight. I was losing muscle mass,” Nicole said.

In October last year, Nicole’s GP referred her to BRHS to treat the fluid issue – and things began to improve.

She lost 6kg, virtually all fluid, in a four-day stay with BRHS before she was released and connected with the Complex Care team.

Kate Smith, a Bairnsdale local born at BRHS, has been a nurse since 1998 and with BRHS’ Complex Care team since 2012.

She said Complex Care helps people to live independently and avoid future hospital admissions with extra support to manage their chronic health conditions.

“Complex care is different to mainstream nursing because you get to meet people in their home environment and you get the luxury of getting to know that person so that we can provide person-centred care,” she said.

“It’s really rewarding when you can find something that can keep people feeling safe, manage their chronic health conditions and remain independent in their home. When you get to visit people at home, you get to see how that all works and what a difference good discharge planning makes.”

Nicole said Kate connected her to a range of specialist services to help her reduce weight and regain fitness. These included BRHS’ physiotherapy, occupational therapy, lymphedema care and Pain Management Centre. Her medication was reviewed and her GP was included in all communication.

Nicole remembers her first meeting with Kate fondly. “Before, I felt stuck. I couldn’t go anywhere. I couldn’t see a doctor. But Kate was awesome. She was friendly, bubbly, caring and compassionate, and that was what I really needed,” she said.

Kate said people with Chronic Obstructive Pulmonary Disease, Congestion Cardiac Failure, Diabetes, memory conditions and a range of cancers were commonly referred to complex care.

Improving a client’s confidence was the key to good complex care, Kate said.

“If people can stay in their own home environment, they’re a lot happier, and I think if we can teach them the skills so that they can look after their condition and be independent, they get more confidence and often do well and often do well living out of hospital,” she said.

“We’re there to help people make the transition and to make things work really well so they keep managing their chronic health conditions and reduce hospital admission.”

Kate even arranged support for Nicole’s partner and daughter through the Australian Government’s Carer Gateway service to ensure that they were OK and that their needs were met while Nicole was on the road to recovery.

Almost a year on, with the aid of the specialist support Kate helped to arrange, Nicole says she has made progress.

”It’s been a whirlwind, and if I didn’t have Kate, I don’t know what I’d do,” she said.

“Physio was probably the most important thing for me, just getting some muscle mass back, and I did some research to help me strengthen everything. Now I’m walking where I couldn’t have and I was sad,” she said.

“Just walking around my house was a struggle but now I’m walking down the street without a problem. I’ve purchased a treadmill so that I can walk and get more movement at home.

“I was just saying to my husband the other day that I used to think that my life is what it is – just pain, that I can’t do anything or go anywhere – but now with the journey I’ve had, I’ve got things to look forward to. Just the simple things I can do that I couldn’t before because even standing, there was pain.”

Kate’s home visits with Nicole have ended for now, but Kate stays in touch over the phone to ensure Nicole’s specialist support is maintained.

”That’s the best part of my job. It makes us feel that all those little things that we do behind the scenes to make things happen feel really worthwhile when we see someone making those kinds of changes, especially for someone who’s worked as hard as Nicole,” she said.