Care Coordination Service
for Older Patients

GP REFERRER DETAILS	Date of Referral	  <<Miscellaneous:Date>>	
Referrer Name	  <<Doctor:Name>>	Last Name	 	
GP Practice	  <<Practice/Location:Name>>	
Address	  <<Practice/Location:Address>>	
Phone No.	  <<Doctor:Phone>>	Email	  <<Doctor:E-mail>>	
Fax No.	  <<Doctor:Fax>>	HealthLink EDI		
PATIENT DETAILS	
First Name	  <<Patient Demographics:First Name>>	Date of Birth	  <<Patient Demographics:DOB>>	
Last Name	  <<Patient Demographics:Surname>>	Gender	  <<Patient Demographics:Gender>>	
Address	  <<Patient Demographics:Full Address Preferred>>	
Home Phone	  <<Patient Demographics:Phone (Home)>>	Email	  <<Patient Demographics:E-mail>>	
Mobile Phone	  <<Patient Demographics:Phone (Mobile)>>	Consent to referral	 <<Consent given>>	
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	  <<Patient Demographics:Country of Birth>>	Main language spoken at home?	  <<Patient Demographics:Language Spoken>>	
Aboriginal	
 <<Patient Demographics:ATSI>>	

Torres Strait Islander	
<<Patient Demographics:ATSI>>	

	(If needed- tick both)	Communication support required? (Please provide details)	 <<Communication support required>>	

	
Employment status	 <<Employment status>>    Benefits   <<Benefits>>   If YES please specify:  	
Are there any risk factors we should be aware of when visiting the home/client?	 <<Risk factors for visit>>  If YES - please specify or attach existing risk assessment if available.	

	
ASSOCIATED DOCUMENTS	
 I have attached the Patient’s Health Summary (if available) <<Health summary attached>>
 I have attached the Patient’s Care Plan (if available) <<Care plan attached>>	

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