Download The Sutherland Hospital - Southcare GP Referral Form

The Sutherland Hospital & Community Health Service
Southcare Intake Office
GP FAX REFERRAL FORM
Referring Doctor <<Doctor:Name>>
Date of Referral <<Miscellaneous:Date (short)>>
Phone number
Provider number
Address
<<Doctor:Phone>>
<<Doctor:Address Line 1>> <<Doctor:Address Line 2>> <<Doctor:City>> <<Doctor:Postcode>>
Patient Details: Surname: <<Patient
Demographics:Surname>>
DOB
<<Doctor:Provider Number>>
Given Names <<Patient Demographics:First
Name>>
<<Patient
Gender <<Patient
DVA No. <<Patient
Demographics:DOB>>
Demographics:Sex>
Demographics:DVA
>
Number>>
Medicare No.

or N/A
<<Patient Demographics:Medicare Number>>
Phone Number <<Patient Demographics:Phone
(Home)>> <<Patient
Demographics:Phone (Mobile)>>
Address (current) <<Patient Demographics:Address Line
1>> <<Patient Demographics:Address
Line 2>>
Suburb <<Patient
State <<Patient Postcode <<Patient Country of Birth <<Patient
Demographics:City
Demogra
Demograp
Demographics:Country of
>>
phics:Stat
hics:Postco
Birth>>
e>>
de>>
Interpreter Required?
Yes

No

Preferred Language
Contact Person: Name
Relationship
(if different to above)
Phone Numbers: Home
Work
Mobile
Is the Southcare worker's safety potentially at risk when visiting this person?
Yes

No

Eg: Pets, Drugs & Alcohol, Patient or Family Behaviour, Domestic Violence
If YES, Southcare Worker will contact referring Doctor
Reason for Referral
Diagnosis / Relevant Medical History:
Medications*
<<Clinical Details:Medication List>>
*If Community Nurse/Pharmacist is to give injections 7 medications in the home, please complete a Medication
Authorisation form and fax with referral- original copy to remain with Patient.
Southcare Services Requested () See Service Details Over Page
N.B. Some services have a waiting list
Aged Care Assessment Team
Pharmacy Liaison
Southcare Outreach Service
Community Nurses
(Community) Physiotherapy
Social Work
Community Options
Occupational Therapy
The Cottage (Dementia)
Continence Advisor
Mobility Clinic
The Retreat (Frail Aged)
Dementia Home Monitoring
Sutherland Heart & Lung Team
Date to
Commence:
Enhanced Primary Care Items: Southcare staff will contact GP to discuss if ticked 
GP will prepare a Care Plan 
GP will contribute to a Care Plan 
GP requests a Case Conference 
PLEASE FORWARD COMPLETED FORM BY FAX TO (02) 9540 7869
The information contained in this facsimile is confidential and is safeguarded by Legislation. It is intended for receipt only by the named
addressee. If you are not the named addressee, any use, disclosure, copying or distribution of the facsimile or any of the information
contained in it is prohibited. Please telephone 9540 7175 if you receive this communication in error.
Summary of Southcare Services
Intake Officer Phone No: 9540 7956
7869

Fax No: 9540
ACAT (Aged Care Assessment Team) - Comprehensively assesses the care and support needs of frail
older people requiring Commonwealth Government subsidised aged care services. If eligible, these services
may include Home Care Packages and/or residential respite or permanent care. ACAT will also provide
advice regarding appropriate Southcare and/or Home and Community Care (HACC) and other services.
NB an ACAT Assessment is not required for HACC services

Community Nursing – The team consists of Registered and Enrolled Nurses providing administration of
medication and injections (including IV antibiotics), wound management, palliative care, personal care,
education and support for clients and carers.

Community Options Program - Provides individual, flexible packages of care with case management for
complex HACC eligible clients.

Continence Advisor - (in client's home or clinic) advice and information regarding continence management,
education and care of urinary catheters; teach and supervise clean intermittent self-catheterisation.
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
Dementia Home Monitoring Program – (HACC funded service auspiced by Southcare) Provides
practical in home support for people with a dementing illness and low care needs. Includes meal and
medication supervision, assistance with personal care, shopping and supervised social outings. Operates in
conjunction with other community support services eg. Home Care, Neighbour Aids, Meals on Wheels.
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
Mobility Clinic - For those experiencing recent declines in their mobility with the potential to improve. Gait
analysis and mobility skills education is provided to improve mobility, safety and confidence.

Occupational Therapy - To assess function and safety in the home, specifically looking at needs for
equipment and modification; High risk / need clients are given priority.

Pharmacy Liaison - To review medication management in the home, and where required liaise with the
hospital.

Physiotherapy – For Mobility issues, chest therapy and house-bound clients requiring physiotherapy. High
risk clients given priority.
Pulmonary Rehabilitation – assessment and gym program with respiratory diagnoses. Requires referral from
specialist.

Social Work -provide consultation and intervention to aged care clients and their families and younger
clients with severe and chronic disability with complex issues in dementia care, suspected elder abuse
cases, hoarding and/or squalor, guardianship and financial management issues and assistance with
accessing services. ACAT assessments for clients under 65.

Southcare Outreach Service- Provides short term acute and sub-acute interventions (up to six weeks, with
an average of 2-4 weeks) by Nursing, Physiotherapy and Occupational Therapy to facilitate enhanced
patient care and safe clinical outcomes.

Sutherland Heart & Lung Health Team - is a community based multidisciplinary team that provide home
monitoring, specialised education and gym based exercise programs to people with chronic heart failure,
chronic cardiac disease and pulmonary hypertension who live in the Sutherland Shire.

The Retreat - (HACC funded service auspiced by Southcare) Day care centre (located at the back of
Southcare) for the frail aged & those with mobility issues who have low care needs. Provides social
activities with transport (Wheelchair hoist on bus) available, enabling Carers to benefit from the respite.

The Cottage - (HACC funded service auspiced by Southcare) Day care centre (located at the back of
Southcare) for people with a dementing illness who have low care needs. Provides social activities with
transport available, enabling Carers to benefit from the respite.
Commonwealth Home & Community Care (HACC) Services
There are also a number of community services, other than those provided by Southcare, to assist Sutherland
Shire residents with disabilities, frail older people and the family and friends who care for them. These
services include Home Care, Meals on wheels, Neighbour Aid etc.
Phone HACC Development Officer on 9548 6000 for further information.
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