Download Best Practice - Gold Coast Primary Health Network

REQUEST FOR CONSULTATION
GOLD COAST HOSPITAL AND HEALTH SERVICE
MUNGULLI SERVICE CLINIC
Aboriginal & Torres Strait Islander Health Worker and CNC Respiratory led
Chronic Disease Wellness Program
Specialising in community based multidisciplinary care for Patients with complex care needs
Supporting Team Care Arrangements (without utilising Medicare items)
Aboriginal and Torres Strait Islander
Chronic Disease Management Service
SEND TO:
Central Intake Unit
Fax: 1300 668 536 OR Phone: 1300 668 936
OR
Secure Transmission Via Medical Object, Healthlink or Argus to:
QHEALTH, GOLD COAST HEALTH Adult Community Health
Central Intake Unit
FROM: <DrName>
<Practice>
Phone: <UsrPhone>
Fax: <UsrFax>
Email:<PracEmail>
Provider Number: <DrProviderNo>
Signature
Does this Patient identify as being of Aboriginal and/or Torres Strait Island descent? <Aboriginal and/or
Torres Strait Island descent?> If no, this Patient is ineligible for this service.
This service is for Patients 18 years and older.
Intensive specialised multidisciplinary nursing and allied health support to assist primary care management for
clients at risk of poor health outcomes due to:
The high impact of chronic health condition/s
Significant co morbidities or barriers to health
Chronic condition/s remain unstable - difficulty achieving effective chronic care management
A culturally safe chronic disease management program for community members with complex needs relating to
Respiratory, Chronic Kidney Disease, Chronic Heart Failure or Diabetes/Pre-diabetes and related chronic
conditions. The Aboriginal and Torres Strait Islander Health Worker is the first point of contact for clients referred.
Multidisciplinary clinics are conducted alternate months across multiple sites.
For enquiries please call Central Intake Unit 1300 668 936 and request the Aboriginal and Torres Strait
Islander Advanced Health Worker.
Date: <TodaysDate>
RE: <PtFullName>
Date of Birth: <PtDoB>
Gender: <PtSex>
Medicare Number*: <PtMCNo>
*[Medicare ineligible patients will incur an appointment fee]
Address: <PtAddress>
Home Ph: <PtPhoneH>
Mobile Ph: <PtPhoneMob>
Alternative Contact Name: <NOKName>
Alternative Contact’s Phone: <NOKContact>
[Alternative contact may be used to contact the Patient if they cannot be reached via the contact details given]
1
<PtFullName>
DOB <PtDoB>
Developed in partnership by General Practice Gold Coast, Gold Coast Primary Health Network and Gold Coast Health January 2016
Interpreter Required? <Interpreter required>
Please specify Language: <If yes - Specify language?>
Is the Patient known to private consultant/s? <Is this Patient known to a private consultant/s?>
If Yes, specify consultant's: <If Yes - specify consultant's name>
Has a Team Care Arrangement been completed? <Has a Team Care Arrangement been completed?>
[Please ensure any current GPMP/TCA is attached.]
Is the Patient on care coordination and supplementary services program? <Is Pt on care coordination &
supplementary services program?>
Has this Patient been referred for Close The Gap medication assistance? <Does the Patient use Close The
Gap Medication?>
Is this Patient newly diagnosed? <Is the Patient newly diagnosed?>
If no, when were they diagnosed? <When was the Patient diagnosed?>
Do you consider this Patient's care needs are: <Do you consider this Patient's care needs are:>
Low Risk - needs are likely to be met in group education.
Complex Care - Has significant co-morbidities or barriers to health outcomes that requires full medical and
multi-disciplinary assessment and treatment planning.
Is the Patient able to participate in:
General community physical activity programs? <Could patient do general community physical
activity?>
A graded exercise program under the guidance of a Physiotherapist or Exercise Physiologist:
<Could pt do a graded program with an Exercise Physiologist?>
Please advise any restrictions that need to be considered during exercise: <Advise any restrictions to
consider during exercise>
Please include as much relevant information as possible about your Patient’s condition to
optimise their chances of being triaged correctly e.g. diagnosis, duration, severity and impact.
Reason for Referral
Key examination findings:
Management provided to date:
Allergies:
<Reactions>
Current Medications:
<SelectedRx>
PLEASE forward with the referral any of the following TESTS if relevant to your Patient
2 <PtFullName>
DOB <PtDoB>
Developed in partnership by General Practice Gold Coast, Gold Coast Primary Health Network and Gold Coast Health January 2016
Chronic Asthma/Chronic Chest Infections
Pre and post SABA Spirometry
COPD
Spirometry
Electrocardiogram (ECG) within last 3 months
Bloods within last 3 months
Chest X-Ray
CT Chest if available
Diabetes/Pre-diabetes
Serial HbA1c
Fasting Blood Glucose/OGTT
Full Lipid Profile TG, HDL, LDL
A random urine albumin: Creatinine ratio
eGFR, FBE, LFTs, U&Es
Eye Screening Report - Optometrist (Optional)
Chronic Kidney Disease
Serial blood pressure readings
Ultrasound of kidneys
Pathology tests
eGFR (serial measures where available)
Urea
Creatinine
Electrolytes
Full Blood Count
Urine Microscopy
Urine albumin or protein Creatinine ratio (serial values if available)
Relevant Medical History:
<SelectedPMH>
<FamilyHx>
Results:
<Ix>
PLEASE make sure ALL relevant results as from above are attached
3
<PtFullName>
DOB <PtDoB>
Developed in partnership by General Practice Gold Coast, Gold Coast Primary Health Network and Gold Coast Health January 2016