community care program referral...

CHHS16/005

Canberra Hospital and Health ServicesOperational ProcedureCommunity Care Program Referral ManagementContents

Contents....................................................................................................................................1

Purpose.....................................................................................................................................2

Scope........................................................................................................................................ 2

Section 1 – Referrals, eligibility criteria and prioritisation........................................................2

Referrals................................................................................................................................2

Eligibility criteria................................................................................................................... 3

Prioritisation......................................................................................................................... 3

Section 2 – Referral management.............................................................................................4

Implementation........................................................................................................................ 5

Related Policies, Procedures, Guidelines and Legislation.........................................................5

Search Terms............................................................................................................................ 5

Attachments..............................................................................................................................6

Attachment 1 - Community Nursing eligibility criteria and prioritisation examples..............7

Attachment 2 – Nutrition Service eligibility criteria and prioritisation examples..................9

Attachment 3 – Occupational Therapy Service eligibility criteria and prioritisation examples.............................................................................................................................12

Attachment 4 – Physiotherapy Service eligibility criteria and prioritisation examples.......15

Attachment 5 – Podiatry Service eligibility criteria and prioritisation examples.................17

Attachment 6 – Social Work Service eligibility criteria and prioritisation examples...........19

Doc Number Version Issued Review Date Area Responsible PageCHHS16/005 1 01/02/2016 01/02/2021 RACC 1 of 20

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

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Purpose

This document outlines operational procedures for the management of referrals to Community Care Program allied health and nursing services. It also defines eligibility and prioritisation criteria for each discipline.

Referrals to Community Care services are accepted from health professionals and any other person in the community. Self referrals are also accepted.

Scope

Community Care Program (CCP) services include: Community Care Physiotherapy, Nutrition, Occupational Therapy, Podiatry, Social Work and Community Nursing.

This procedure applies to staff in the Community Care Program and Community Health Intake (CHI).

This procedure can be used by staff in the Community Care Program and Community Health Intake to inform referring parties of the processes for referral.

Section 1 – Referrals, eligibility criteria and prioritisation

Community Care services are generally provided in health centre clinics. With the exception of CCP Podiatry, a home service is provided for those patients who, for medical reasons, are unable to attend a clinic appointment, or where assessment/treatment is more appropriately provided in the home environment.

Where an environmental assessment of the home has determined that care cannot be provided safely in the home, other ways of providing the service will be considered in consultation with the patient and the manager (for further information see: Providing Clinical Health Services in an Off Campus Environment Procedure).

ReferralsVerbal consent from the patient must be sought prior to the referral being made.

Referral forms must be completed in full and must clearly identify the referring person’s name and contact details. The reason for referral or service requested should be clearly documented. Where applicable, treatment and medication orders must be attached.

All referrals must be made through Community Health Intake via: Telephone - 6207 9977 or Fax - completed CHI Referral Form to 6205 2611 or Email - completed CHI Referral Form to [email protected]



mailto:[email protected]

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Note: Patients who are eligible for the Commonwealth Home Support Program (CHSP) must be directed to the My Aged Care portal if they are referring for community nursing, occupational therapy, podiatry and physiotherapy services. CHI will receive or retrieve the referrals from the My Aged Care portal, check they meet service criteria, allocate initial priority and make appointments where required.

Referrals within Community Care (for example from one CCP discipline to another CCP discipline) will also need to go through CHI (and if applicable via My Aged Care portal), with the exception of referrals between CCP Podiatry and CCP Footcare.

Eligibility criteriaTo be eligible for Community Care services patients must have either a permanent, or temporary, Australian Capital Territory (ACT) residential address as registered in the patient administration system (ACTPAS).

Community Care does not provide clinical services to residents of Residential Aged Care facilities. Clinical Nurse Consultants/Clinical Specialists can provide consultancy services to these facilities. Patients in independent living units within retirement villages are eligible for Community Care services.

Eligibility criteria for each discipline are outlined in attachments (see attachments 1-6).

Eligibility criteria are communicated to CHI (via scripting). The service manager reviews the scripting regularly and informs CHI of any changes. Significant changes to scripting, such as where eligibility or access will be affected, will need to be discussed with and approved by the CCP Allied Health Services or CCP Nursing Services Manager.

If patients are eligible for the National Disability Insurance Scheme (NDIS), the requested service can be provided; however, the funding for this service will now come from the NDIS. The service needs to be included on the patient’s Plan so RACC can bill the National Disability Insurance Agency for the service.

Patients not eligible for Community Care services are advised to seek private services.

PrioritisationEach referral is prioritised, and a time frame for first intervention is allocated based upon clinical need. Priority is entered into ACTPAS as a category, as follows: For allied health services:

o Category 2a – to be seen within 2 working dayso Category 2 – to be seen within 10 working days o Category 3 – to be seen within 50 working days

For nursing services:o Category 2a – to be seen within 24 hourso Category 2 – to be seen within 2 working days



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o Category 3 – to be seen within 14 days

Back to Table of Contents

Section 2 – Referral management

The date of the referral is the date it is created in ACTPAS and should not be backdated.

1. CHI nursing staff create an ACTPAS referral and prioritise according to the clinical information that is provided at that time.

2. CHI nursing staff allocate the referral to the appropriate discipline/regional team.

3. If applicable to the service, CHI then allocate an appointment time. Note: if CHI staff cannot find an appointment within the recommended timeframe, CHI will notify the service (via email to manager and generic inbox).

4. Each discipline/team has a designated staff member(s) who checks and actions referrals. This staff member: amends the prioritisation category if required ensures that a contact, or appointment has been made within the designated

prioritisation category timeframe allocates the referral to a clinician/team where necessary.

5. Referrals to community nursing on weekends (from 1600hrs on Friday until 0800hrs on Monday) and public holidays must be faxed or scanned to the Link team (After Hours community nursing). Referrals are triaged, the referrer must phone the Link After Hours Coordinator on

0417 434 990 and discuss the referral. If the referral is appropriate for After Hours services, the referrer must fax the

completed referral form to the Link team on 6205 2829 and to CHI on 6205 2611.CHI will create a referral to Link if the service commences on the weekend.

Note: If the patient requires an interpreter, the staff member who makes the appointment must also book the interpreter. This can be CHI staff, Health Centre (HC) Administration staff, or clinical staff. When a staff member reschedules a service, the staff member must also reschedule the interpreter booking.



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Note: Patients should only have one referral open to the service. Where CHI receives a new referral request and there is an existing referral to the specified service in ACTPAS, CHI will add this information to the current open referral, or contact the service manager to discuss. It is not the responsibility of CHI to close referrals.Where a new referral is received by the service and a referral is still open in ACTPAS, it is the responsibility of the service to manage the referral.


Implementation

This procedure is available to all ACT Health staff on the ACT Health Policy Register. This procedure will be communicated to Community Care staff at team meetings. New staff will be educated on the referral management procedures through existing orientation programs.


Related Policies, Procedures, Guidelines and Legislation

LegislationHealth Professionals Act 2004Health Records (Privacy and Access) Act 1997

Policies and ProceduresProviding Clinical Services in an Off Campus Environment ProcedureClinical Records – Records Management ManualAdministrative Records Management PolicyClinical Records – Release or Sharing of Clinical Records or Personal Health Information ProcedureConsumer Feedback Management Policy and Procedure Community Based Clinical Records Procedure


Search Terms

Community Care Program, Community Health Intake, CHI, Referral, Eligibility, PrioritisationCommunity Nursing, Nutrition, Occupational Therapy, Physiotherapy, Podiatry, Social Work




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Attachments

Attachment 1 - Community Nursing Service eligibility criteria and prioritisationAttachment 2 - Nutrition Service eligibility criteria and prioritisationAttachment 3 - Occupational Therapy Service eligibility criteria and prioritisationAttachment 4 - Physiotherapy Service eligibility criteria and prioritisationAttachment 5 - Podiatry Service eligibility criteria and prioritisationAttachment 6 - Social Work Service eligibility criteria and prioritisation

Disclaimer: This document has been developed by ACT Health, <Name of Division/ Branch/Unit> specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended Section Amended Approved By7 March 2016 Section 1 – paragraph added to

include reference to NDISPolicy Team Leader



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Attachment 1 - Community Nursing eligibility criteria and prioritisation examples

Community Nursing Services include: Wound management and nurse practitioner review clinic Continence and urinary catheter management Primary palliative care Post chemotherapy support, management of central venous access devices Drain management Support with self management of gastrostomy, Home Parenteral Nutrition, cervical collar

and tracheostomy Stoma clinic , pre and post operative education Self Management of Chronic Conditions courses Education and short term monitoring of blood pressure, blood glucose levels, medication

administration.

Referrals for short term administration of antibiotics via intramuscular route are accepted. Community nursing accepts referrals for administration of antibiotics via central venous access device only if the patient is under the care of a medical specialist in the ACT.Community nurses do not accept referrals for administration of antibiotics via cannula or butterfly device.

Community nurses do not administer the first dose of each course or episode of the following medications: any parenteral antibiotic, any intravenous medication, insulin, injectable anticoagulants, chemotherapy agents, biological modifiers.

Not eligible for services: Residents in Residential Aged Care facilities.

Note: Clinical Nurse Consultants/Clinical Specialists can provide consultancy services to these facilities.

Department of Veterans Affairs (DVA) cardholders: DVA Gold card holders are eligible for DVA provider services. Referrers should seek the services of a private provider in the first instance. The Yellow Pages directory or DVA will provide details of private service providers.

Patients with the intent to claim for Third Party Liability or Worker’s Compensation (or who’s claim has not been approved) are eligible for the service should they wish not to attend a private nursing service. They are advised that their insurer will be invoiced in the event that their claim is approved or upon settlement of the case.



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Prioritisation examplesCategory 2a Examples include:

Post chemotherapy monitoring - completion of first cycle Syringe driver management Severe constipation (administration of fleet or other enema) Acute pain control including administration of Schedule 8 and

Schedule 4 medications Routine control of vomiting and administration of antiemetic Administration of medications such as eye drops, biological modifiers,

intravenous antibiotics and anticoagulants as ordered by medical officer

Post insertion of Peripheral Inserted Central Catheter (PICC) Blood glucose monitoring/insulin administration and education (short

term) Wound care for infected heavily exudating wounds or as ordered by

medical officer Drain care where nurse assistance is required Vacuum Assisted Closure (VAC) dressings Tracheostomy/laryngectomy tube monitoring Chest drain monitoring.

Category 2 Examples include: Routine post chemotherapy monitoring Central Venous Access Device (CVAD) maintenance and monitoring Routine bowel management (short term enema/suppository

administration, laxative advice) Non daily (not infected or heavily exudating) wound dressing Catheter, stoma and gastrostomy tube management and education Short term monitoring of blood pressure Routine post cardiac surgery monitoring.

Category 3 Examples include: Routine care of Indwelling Catheter (IDC) or Suprapubic Catheter (SPC) Weekly/fortnightly/monthly injections Removal of surgical clips Continence assessments Stoma review Portacath management.



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Attachment 2 – Nutrition Service eligibility criteria and prioritisation examples

Not eligible for services: Third Party Liability or Workers compensation cases should be directed to private

providers. These can be found in the Yellow Pages directory. Patients on Home Care Package Level 3 or 4. Residents in Residential Aged Care facilities. Department of Veterans Affairs (DVA) cardholders:

DVA Gold card holders are eligible for DVA provider services. Referrers should seek the services of a private provider in the first instance. The Yellow Pages directory or DVA will provide details of private service providers.

Some people are not eligible for CCP Nutrition services as they can be more appropriately referred to other services. These are: Patients with diagnosed diabetes mellitus (Type 1, Type 2, Gestational Impaired

Glucose), Impaired Glucose Tolerance or Impaired Fasting Glucose.These patients are seen by ACT Diabetes Service Dietitians. The Diabetes Dietitian can refer clients to CCP nutrition groups.

Patients with food allergy and complex food intolerances. These patients are seen by Acute Support Nutrition.

Patients with diagnosed eating disorders (Anorexia Nervosa, Bulimia, Eating Disorders Not Otherwise Specified). These patients may be eligible for services offered by Mental Health (Eating Disorder Program) or will need to access private services.

Patients accessing Rapid Assessment of the Deteriorating Aged at Risk (RADAR) or Transitional Therapy Care Program. These patients are seen by the dietitian assigned to these programs.

Patients undergoing haemodialysis at Canberra Community Dialysis Centre (CCDC), Acute Dialysis unit Canberra Hospital (Ward 8A), home haemodialysis patients, peritoneal dialysis patients. Note: Community Health Centre dialysis patients are seen by CCP Nutrition.

Patients receiving chemotherapy treatment at Canberra Hospital.These patients are seen by Acute Support Nutrition.



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Prioritisation examplesCategory 2a Patients receiving enteral nutrition aged ≥ 18 yearsCategory 2 Presenting issues include:

Malnourished: 5% unintentional weight loss in the last 3-6 months High risk of malnutrition. This may be indicated by: recent

unintentional weight loss of 3kg in 3 months, poor appetite or the client looking obviously frail or underweight or body mass index (kg/ m2) < 18.5

Needing advice/assistance with prescribed nutritional supplements Chronic Obstructive Airway Disease, Heart Failure Palliative care patients Newly diagnosed and active (5-8 weeks) minor gastrointestinal

disorders (e.g. diarrhoea, diverticular disease, irritable bowel syndrome, reflux, gall bladder disease, stoma, peptic ulcer disease)

Diet therapy to decrease blood lipid profile and high blood pressure (medical officer referral for pre-medication diet trial)

Nutrient deficiency diagnosed by a medical officer Poor wound healing for newly diagnosed wound (3 months) Poor swallowing (speech pathology referral also indicated) Thickened fluids (speech pathology referral also indicated) Texture modifications (for swallowing issues or gastrointestinal

disorders e.g. after bowel obstruction) Advance renal failure with Glomerular Filtration Rate (eGFR) <

30ml/min, those receiving haemodialysis at Belconnen and Tuggeranong Community Health Centres only. Book into renal specific nutrition clinic only.

Note: the above criteria may include patients with conditions listed in Category 3, but presenting issue is in this category i.e. Category 2)

Category 3 Presenting issues include: General nutrition issues, high fibre, vegetarian/vegan Poor wound healing in long standing wound (> 3 months) Weight management: obesity/ overweight/ binge eating — only offer

Adult Healthy Weight Group* (see * on p11) Heart/cardiovascular disease: raised blood lipids, high blood pressure -

only offer Heart Fare*(see * on p11) Long standing (> 8 weeks) minor gastrointestinal disorders (e.g.:

constipation and diarrhoea, diverticular disease, irritable bowel syndrome, reflux, gall bladder disease, stoma, peptic ulcer disease)

Non-alcoholic fatty liver disease (offer Adult Healthy Weight Group) Hepatitis (not cirrhosis) requiring weight reduction (offer Adult

Healthy Weight Group) Inflammatory or autoimmune disease: arthritis, gout Neurological disorders: Parkinson's disease, Stroke, Multiple Sclerosis,

Motor Neuron Disease (unless malnutrition or poor swallowing – Category 2)

Kidney disease: with Glomerular Filtration Rate (eGFR) > 30ml/ min,



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kidney stones, post renal transplant. Book into general nutrition clinics Polycystic Ovarian Syndrome (PCOS) (no Diabetes).

*For Weight Management and Cardiovascular Disease offer individual appointment only if: the patient has completed appropriate group sessions an interpreter is required behavioural or significant mental health issue is identified disability would affect ability to learn patient has been diagnosed with heart failure by a medical officer medical officer has requested immediate diet therapy prior to administration of

medication.



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Attachment 3 – Occupational Therapy Service eligibility criteria and prioritisation examples

The Occupational Therapy (OT) service provides prescription of home modification and Assistive Technology (AT) to address issues of home safety and independence for adult patients with physical disabilities.

Not eligible for services: Third Party Liability or Workers Compensation cases should be directed to private

providers. These can be found in the Yellow Pages directory. Patients on Home Care Package unless approved by the Regional Assessment Service

(RAS) via My Aged Care portal. Residents in Residential Aged Care facilities. Department of Veterans Affairs (DVA) cardholders.

DVA Gold card holders are eligible for DVA provider services. Referrers should seek the services of a private provider in the first instance. The Yellow Pages directory or DVA will provide details of private service providers. DVA White cardholders will be ineligible if the issue is covered by DVA.

Some people should, in the first instance, be referred to more appropriate services. These are people who are: Housing ACT tenants where the reason for referral is home modifications, checking on

completed modifications from other therapists, relocation or new application to an appropriate Housing ACT residence. These patients are to be forwarded to the Housing ACT OT and Disability Modifications Coordinator.

Over 65 years old (or Aboriginal Torres Strait Islander Peoples who are over 55 years), are at increased risk of falls and if they have not received falls clinic intervention in the last two years – they are eligible for the Falls Clinic.

To have pre-elective orthopaedic surgery assessment – they can attend the primary joint replacement education sessions to which an OT attends.

Receiving home based palliative care – they can access OT services via the CNC for Palliative Care. Referrals can be made by phoning: 6264 7331.

People with developmental disabilities who are eligible for OT services with relevant National Disability Insurance Scheme (NDIS) Providers or Therapy ACT (refer to eligibility criteria for Therapy ACT). Examples include:o Pervasive Developmental Disorder, Cerebral Palsy, Intellectual Disability, Muscular

Dystrophy, Spina Bifida, Hydrocephalus, seizure disorders, and other genetic syndromes where the disability presents before the age of 18 years

o People with permanent disability as a consequence of acquired brain injury or disease process that occurred after birth and prior to 18 years.

Eligible for OT services through the RACC, Community Rehabilitation Service (CRT) or Rehabilitation at Home (RaH) – referral via CHI (see Community Rehabilitation Team Eligibility Criteria policy).

Care agencies wanting a Work Safety risk assessment for their employees must access private providers. Care agencies wanting advice regarding care hours must access private providers.



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People seeking a service only directly related to low vision – they should be referred to Vision Australia (phone: 1300 84 74 66 and ask for the Canberra Office).

More appropriate for review through Rapid Assessment of the Deteriorating Aged at Risk (RADAR) program should be considered where deterioration is due to medical conditions in patients over 65 that are likely to result in hospitalisation (referrals are made by GP).

Requesting a functional review to commence NDIS planning with no specific intervention indicated.

Prioritisation examplesCategory 2a Rapid Response Pathway – Patients assigned to the Rapid Response pathway require

urgent assessment and intervention by an OT in order to prevent/treat a pressure related injury or prevent admission/readmission to hospital.Examples include: Assistive Technology (AT) required for community patients with very

high Waterlow score or existing pressure injury. An AT issue for a patient at imminent or high risk of injury or

institutionalisation.Category 2 Examples include:

Recent decline in patient’s mobility placing patient and/or carer at high risk of injury. Requires an assessment for home modifications and/or AT to address risk to patient and/or carer within 10 working days

Recent deterioration in health condition within the previous month that limits the patient’s functional ability in daily living tasks

Patient has been experiencing multiple mechanical falls and is not appropriate to attend Falls Service.

Category 3 Examples include: Request for home modification prescription to promote general safety

and independence Prescription for replacement or long term AT needs.

Funding for Assistive Technology (AT) or home modifications

The service is unable to guarantee or predict approvals or levels of funding. The OT service brochure outlines the role of the OT for the patient’s information.

The need to source funds for AT or home modifications recommended by the OT should be discussed with the patient or their carer at the care planning stage. The capacity and needs of the patient in relation to funding advocacy must be considered and documented in the care plan. Where the patient is unable to undertake the steps necessary to organise funding or AT purchase, the OT will refer patients to alternative resources/services to assist this process. This requires patient’s consent.

It is outside the scope of the CCP OT role to provide advocacy for funding on behalf of patients beyond the standard public funding available. Patients who require formal advocacy Doc Number Version Issued Review Date Area Responsible PageCHHS16/005 1 01/02/2016 01/02/2021 RACC 13 of 20


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support for funding assistance should be referred to a Community Agency for assistance. The OT may provide a recommendations report to the patient to support applications for funding.



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Attachment 4 – Physiotherapy Service eligibility criteria and prioritisation examples



(RAS) via My Aged Care portal. Residents in Residential Aged Care facilities. Department of Veterans Affairs (DVA) cardholders:


Physiotherapy services include:1) Musculoskeletal Conditions in adults and children (over 1 year of age):

Musculoskeletal pain Acute soft tissue injury Treated fractures, dislocations, and post orthopaedic surgery Acquired musculoskeletal pathologies e.g. arthritis, connective tissue disorders,

complex regional pain syndromes Mobility issues due to an acute injury or degenerative disease Musculoskeletal conditions in patients with neurological disorders.

Note: Patients with a diagnosis of Stroke which is < 2 years or Traumatic Brain Injury (TBI) < 18 months should be referred to Rehabilitation Aged and Community Care (RACC) rehabilitation services/Community Rehabilitation Team (CRT) initially. This is a more appropriate multi-disciplinary service to meet their rehabilitation goals. Children (< 18 years old) with neurological or developmental conditions should be referred to Canberra Hospital Physiotherapy Outpatients Department or Therapy ACT.

2) Respiratory Conditions in adults and children in the following circumstances: Acute respiratory illness or exacerbation of existing respiratory conditions with

difficulty clearing secretions. Deteriorating respiratory function with co-existing chronic neurological conditions. Short term management of Cystic Fibrosis (CF) patients, via direct referral from The

Canberra Hospital Physiotherapy Department.It is recommended that a GP review has taken place prior to the first physiotherapy appointment for respiratory conditions.

3) Adults and children with continence issues and pelvic floor dysfunction/pain.

Those eligible for other specialised services i.e. antenatal and postnatal women up to 12 months post partum, and women attending TCH outpatient clinics, should be referred on to the specialised services e.g. Women’s Youth and Children Physiotherapist.

Prioritisation examplesDoc Number Version Issued Review Date Area Responsible PageCHHS16/005 1 01/02/2016 01/02/2021 RACC 15 of 20


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Category 2a Examples include: Acute respiratory conditions Patients with a high risk of falls/ recent history of multiple falls Acute onset of compromised mobility where home mobility

assessment and/or equipment provision is needed to facilitate safe mobility at home.

Category 2 Examples include: Orthopaedic surgery as directed by surgeon Removal of immobilising cast or Plaster of Paris (POP) Recent musculoskeletal injury/onset of severe pain < 1 month

duration.Category 3 Examples include:

Longer term onset of injury/pain < 1 month duration Chronic musculoskeletal conditions.



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Attachment 5 – Podiatry Service eligibility criteria and prioritisation examples

To be eligible for CCP Podiatry services patients must hold one of the following concession cards: Current Centrelink Health Care Card (yellow and green). Current Centrelink Pensioner Concession Card (blue and red). International Health and Medical Services Health Card (IHMS). Or, who is a prisoner/detainee from the correctional facilities of the ACT. Holds formal refugee status.

Patients who do not meet above criteria may be provided care in exceptional circumstances where they have a service history of chronic ulceration, are classified at high risk of re-ulceration and require regular ongoing podiatric treatment. In these circumstances a referral is accepted from the CCP Nurse Practitioner – Wound Management, or from the ACT Health Diabetes Service Senior Podiatrist.



(RAS) via My Aged Care portal. Residents in Residential Aged Care facilities. Department of Veterans Affairs (DVA) cardholders.



Active limb threatening condition (also suggest presentation to GP or Emergency Department)

Foot ulcer / wound Suspected bacterial infection.

Category 3 Examples include: Foot assessment and education Other presenting issues e.g. nail care, corns, pes planus/flat feet, foot

orthotic replacement Footsure health promotion program.

Alternative service for Category 2a patients - The High Risk Podiatry Clinic, The Canberra Hospital (ACT Diabetes Service) may be appropriate for Category 2a patients (those with an active foot wound). Phone: 6244 3794.



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Patients who have been seen < 12 months and were discharged: These patients will have had their podiatry referral closed by the Podiatrist and should not be offered another Podiatry appointment until 12 months after their last appointment. This aims to improve access for eligible patients and provide podiatry services in a timely manner that is relevant to clinical need.

In the event a patient requests another appointment before 12 months has lapsed for a new or different issue than the original referral, the Podiatry team must be consulted BEFORE another Podiatry appointment is made. Contact can be made via the generic podiatry inbox [email protected] .

Foot Care ServiceThe Community Care Program Foot Care Service provides basic foot care for those in the community who are assessed by a CCP Podiatrist as low risk but unable to self care. A referral from a CCP Podiatrist is required.

To access the Foot Care Service, patients must: Meet eligibility criteria as per Podiatry Service Eligibility Criteria (see above) and, have

been assessed in the last 12 – 18 months by an ACT Health Podiatrist as being of low pedal risk and suitable for ongoing appointments with the Foot Care Service.

The patient must also be deemed to be unable to self care or to not have access to a carer who can provide basic foot care. Factors which would affect a patient’s ability to self care include significant impairment of vision (i.e. legally blind), function or mobility.

Patients who are assessed as low risk and have complex foot care requirements (corns and nail difficulties) are not clinically appropriate for the Foot Care Service. These patients should be encouraged to access alternative podiatry services such as private services listed in the Yellow Pages directory. Patients who are assessed as low risk and have a chronic condition may be able to access a Medicare rebate for Allied Health visits through a GP Management Plan.



mailto:[email protected]

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Attachment 6 – Social Work Service eligibility criteria and prioritisation examples

Social Work Services include: Support for adjustment to a recent diagnosis, significant health condition, including

chronic conditions Support regarding enhancing client’s self care in the community and support for their

spouse/carers Community support that may assist in the prevention of social admissions into hospital

including support for their spouse/carers Grief and loss support with respect to changing health status, health related

bereavement and death of a spouse in the elderly Counselling support for health related reactive depression.


providers. These can be found in the Yellow Pages directory. Patients on Home Care Package Level 3 or 4. Residents in Residential Aged Care facilities. Department of Veterans Affairs (DVA) cardholders.


Clients who are eligible for other specialised psychosocial services should be redirected to the relevant service: Cancer related referrals should be referred to Cancer Psychosocial Service. People whose presenting illness relates to a Mental Health diagnosis should be referred

to Mental Health Services. Alcohol and other drug problems should be referred to the Alcohol and Other Drugs

Program. Clients eligible for Therapy ACT services should be referred to Therapy ACT.



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Support relating to a health related death in crisis or for Coronial referral and support < 3 weeks

Death of carer where no other support is in place.Category 2 Examples include:

Post acute discharge support Carer stress Prevention of social admissions to hospital Adjustment to a life threatening diagnosis Counselling support for health related reactive depression.

Category 3 Examples include: Adjustment to a medical diagnosis Aged persons self care in the community Routine bereavement support (non-crisis, < 3 weeks) Self Management of chronic health conditions.



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