Care Coordination Service
for Older Patients

GP REFERRER DETAILS	Date of Referral	  <TodaysDate>	
Referrer Name	  <DrFirstName>	Last Name	  <DrSurname>	
GP Practice	  <Practice>	
Address	  <UsrAddress>	
Phone No.	  <DrPhone>	Email	  <DrEmail>	
Fax No.	  <DrFax>	HealthLink EDI		
PATIENT DETAILS	
First Name	  <PtFirstName>	Date of Birth	  <PtDoB>	
Last Name	  <PtSurname>	Gender	  <PtSex>	
Address	  <PtPOAddress> <PtPOCity>  <PtPOPostcode>	
Home Phone	  <PtPhoneH>	Email	  <PtEmail>	
Mobile Phone	  <PtPhoneMob>	Consent to referral	  <Consent to referral Yes> YES	 <Consent to referral No> NO	
ELIGIBILITY CRITERIA / REFERRAL REASON	
Patient must satisfy two (2) or more of the following:
1)	☐ Yes, 75+ yrs old and frail. Residing in Hornsby, Ku-ring-gai or Ryde council areas
2)	☐ Yes, living with three or more chronic health conditions/comorbidities.
3)	☐ Yes, would benefit from Care Coordination support to reduce risk of admission to hospital.	
Key Issues Identified (e.g., no current supports at home, no community care supports in place, multiple follow-up appointments need to be organised, home environment may need review, assistive equipment required, etc.)		
ADDITIONAL CLIENT INFORMATION	
Country of birth	  <PtEthnicity>	Main language spoken at home?	  	
Aboriginal	  <Aboriginal Yes> YES	<Aboriginal No> NO	(If needed- tick both)	Communication support required? (Please provide details)	  <Communication support needed Yes> YES   <Communication support needed No> NO	
Torres Strait Islander	  <Torres Strait Islander Yes> YES	<Torres Strait Islander No> NO				
Employment status	  <Full time work> Full-time <Part time work> Part-time  <Unemployed> Unemployed  <Benefits> Benefits, please specify:	
Are there any risk factors we should be aware of when visiting the home/client?	  <Risk Factors for visit No> NO	  <Risk factors for visit Yes> YES - please specify or attach existing risk assessment if available.	
		
ASSOCIATED DOCUMENTS	
 <Health summary attached> Yes, I have attached the Patient’s Health Summary (if available)
 <Care Plan attached> Yes, I have attached the Patient’s Care Plan (if available)	

OFFICE USE ONLY   Date: ………………………….      ☐ Accepted	☐ Referral not accepted, reason: …………………………………………….…………………………………