Community Nursing Services – Canberra / Queanbeyan

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Supporting Health at Home with Community Nursing

For seniors with Home Support Packages, or people living with disability under the NDIS, remaining at home is more than a preference - it’s essential for independence, dignity, and quality of life. However, managing complex health needs at home can be challenging without the right support. This is where SchemeWise community registered nursing services play a vital role, offering tailored, in-home care that helps individuals stay safe, well, and connected to their community.

With the right nursing support, people in Aged Care or on the NDIS can live safely, independently, and with confidence in their own environment. SchemeWise nursing services demonstrate how professional, compassionate care can bridge the gap between hospital and home—empowering individuals to take control of their health while continuing to live life on their terms.

SchemeWise community nursing services are available across Canberra (ACT)  and in Queanbeyan (NSW).

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A Trusted Local Option for Aged Care and NDIS Participants

Whether accessed through My Aged Care, the NDIS, or privately, SchemeWise nursing services provide flexible, high-quality support tailored to individual needs. Their focus on clinical expertise, personalised care, and collaboration makes them a valuable partner for anyone seeking to manage their health at home.

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Person-Centred Approach to Care

SchemeWise community nursing services are built around a person-centred model, meaning care is designed with the individual’s goals, preferences, and daily realities in mind. Rather than applying a one-size-fits-all approach, SchemeWise registered nurses work closely with each person to understand their health conditions, lifestyle, and aspirations.

This holistic, “whole-person” approach considers physical, cognitive, and psychosocial needs - ensuring that care supports not just medical stability, but overall wellbeing. 

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Managing Health Conditions at Home

One of the most significant ways SchemeWise supports people is through ongoing health management. SchemeWise registered nurses assist with a wide range of clinical needs, including:

• Medication administration and monitoring
• Medication training for workers and family (understanding medication side effects or knowing when to call for help)
• Wound care and pressure injury management
• Chronic disease management (such as diabetes, COPD, or stroke recovery)
• Continence and catheter care (including suprapubic catheter management)
• Monitoring vital signs and overall health status

By delivering these services at home, individuals can avoid unnecessary hospital visits and maintain continuity in their care. 

Nursing services can be funded through a MyAgedCare Home Support Package, or NDIS Plan (Core or Capacity - Improved Daily Living).

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Supporting Complex and Changing Needs

Health needs can change over time. SchemeWise community nurses provide both ongoing support and short-term interventions when circumstances shift.

For example, they can provide:

• Additional clinical insight when needed for care planning (and using support worker services)
• A reassessment is required for Aged Care or NDIS funding reviews (providing professional input into a person's support needs)
• Training support worker services to deliver particular assistance at home 
• Training support services (this is a delegated responsibility and ongoing regular direct/non-direct supervision from a nurse is also necessary in these circumstances)

SchemeWise community registered nursing assessments provide detailed insights into how a person’s condition affects daily life, helping ensure the right supports are in place to maintain independence. 

NOTE: Nurses cannot delegate an activity to support workers if a person's condition is NOT stable or fluctuates over time. Some supports cannot be delegated such as medication injections.

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Enabling Independence Through Care Planning

A key strength of SchemeWise services is their focus on proactive care planning. SchemeWise registered nurses collaborate with customers, families, and support teams to develop structured health plans that align with individual goals.

These plans may include:

• Daily health routines
• Daily care plans for support worker implementation / use
• Risk management strategies for home safety
• Emergency preparedness planning (health management considerations)
• Nutrition and lifestyle guidance

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Working Alongside Families and Support Teams

Effective home care is rarely delivered in isolation. SchemeWise community registered nurses actively collaborate with:

• General practitioners (GPs)
• Allied health professionals
• Support workers and carers
• Family members

They also provide training for support workers, ensuring everyone involved understands how to safely manage medications, equipment, and specific health conditions. This coordinated approach improves outcomes and reduces risks in the home environment. 

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Supporting Mental Health and Wellbeing

Health is not just physical. SchemeWise recognises the importance of mental and emotional wellbeing, particularly for individuals living with chronic illness, neurological conditions, or age-related changes.

Their services include support for:

• Cognitive conditions such as dementia
• Psychosocial challenges in disability and ageing conditions
• Adjustment to life transitions and changing abilities

By addressing these areas, SchemeWise community nursing care supports the whole person, and their families and support networks. 

NOTE: We do not provide support for mental health problems alone. Rather mental health is supported in terms of its overlay with many other cognitive, neurological or physical problems and supporting the whole person from a biopsychosocial perspective.

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Helping People Stay Connected to Their Community

Remaining at home allows people to stay close to their routines, relationships, and communities. SchemeWise nurses support this by focusing on functional independence—helping individuals maintain mobility, manage daily activities, and continue engaging in social life.

This approach not only improves quality of life but also reduces the likelihood of early entry into residential care.

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Getting started is easy too...

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Make a confidential enquiry via our contact form or phone us on

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GPs, allied health or hospitals can complete our NDIS referral form

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GPs, allied health or hospitals can complete our MyAgedCare referral form

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DISCLAIMER: We prefer your enquiry before completing a referral form so that we can advise on our capacity to assist in any patent circumstance. Our registered nurses are seasoned professionals and male and female staff are utilised. We may not be able to offer a choice of nurse and advise that the most appropriate nurse is necessary within their scope-of-practice considerations. This is a regulated means by which ALL registered nurses must have relevant experience and training in any particular area, to be able to practice and provide a service with professional competence.