Palliative Community Supportive Care Clinic - Information for Health Professionals

Our clinic is located in the Professorial Suite, Level 2, High Street Building, Prince of Wales Hospital Randwick. Phone: (02) 9382 0400.

Clinic Name	Clinic Day	Clinic Time
Palliative Community Supportive Care Clinic	Tuesday	8.00 am - 2.00 pm

Our multidisciplinary team includes:

Clinic consultant
Dr Rebecca Strutt	Palliative care specialist

 

Other health professionals
Annaleise Collier	Dietitian
TBA	Speech Pathologist
Patrick Nay	Pharmacist
Michelle Neville	Occupational Therapist
Mary Santos	Physiotherapist
Caroline Pugh	Clinical Nurse Consultant

 

Inclusion criteria

To be referred to the Palliative Community Supportive Care Services, a person must fit ALL of the below criteria:

1. Must live within South Eastern Sydney Local Health District
2. Must have a medical referral from a GP or specialist involved in their care
3. Must have a diagnosis of a life limiting/progressive illness
4. Must require Multidisciplinary team input (Medical, Allied Health or Nursing)

A patient must fit at least ONE of following:

• Health professional would not be surprised if the patient died in the next 12 months.
• Complex and increasing symptom burden
• Persistent symptoms, despite optimal treatment of underlying condition(s)
• Deterioration in functional performance status and increased support needs
• The person (or family):
• Asks for palliative care
• Wishes to change goals of care to focus on quality of life
• Progressive weight loss of more than 10% dry body mass, in last 6 months
• Two or more unplanned acute admissions in last 12 months
• New sentinel event in the last 6 months, resulting in significant functional loss/change

Exclusion criteria

List of exclusion criteria	Alternative referral pathway
Actively dying	Refer patient to the local Palliative Care Community Service
Rapid deterioration thought to be in the last 3 months of life
Requiring high frequency of palliative nursing and medical support in the community
Declining referral to palliative care	Flag with GP/primary referral to readress referral at a later date
No MDT needs	Refer to relevant outpatient clinic/s where single discipline needs can be addressed.
Patient has no primary or specialist care team to continue their care on discharge from service or to enact recommendations.	Primary referrer to consider.

Please note that this service is not the appropriate place to assist with de novo NDIS applications, primary mental health diagnoses, complex behavioural or chronic pain management. We are happy to support referrers in navigating to the correct service for people with these additional needs.

*if the referrer feels strongly that a patient has unmet needs and fulfils other inclusion criteria, further case discussion is suggested with the Medical Specialist/CNC about appropriateness of such a referral.

Prince of Wales Hospital Outpatient Department is using electronic referrals. eReferrals are electronic SmartForms that can be sent directly to the hospital facility from your practice system or the MyHealthLink Portal. An eReferral is an electronic document that can be sent securely, replacing other methods such as faxing or posting paper referrals. The above solutions enable referrals to be sent, received, and managed electronically. Referrers and patients will also receive notification of referral outcomes.

If your patient is eligible for treatment, please read this information on how to submit your referral.

Private referrals (bulk-billed through Medicare)

All patients have the right to choose to be treated as a public or private patient for outpatient attendances. If your patient chooses to be treated privately and bulk-billed through Medicare, your referral must meet the following criteria:

• You must address the referral to one Consultant from our Specialist team, not the hospital, clinic, outpatient department or JMO
• You must sign and date the referral, and include your provider number and practice address
• You must state the period of referral in months, or refer “indefinitely”
• You must provide this referral on or prior to the appointment date.

Please note that it is inappropriate for our administration team to recommend a Consultant for your patient. We have listed the names and specialties of our Consultants above to help you decide on the most appropriate practitioner. 

Who will contact your patient to schedule an appointment?

Once the eReferral has been received and accepted a notification will be sent to the referrer and patient. Appointment details will be provided via letter to the patient and GP. If an appointment cannot be made, we will send patients a letter confirming that they are on the outpatient waiting list for the next available appointment. Patients will receive an SMS reminder 3 days before their appointment. 

Who can you contact to follow up on a referral? 

You may contact (02) 9382 0422 to follow up on a referral.

What is the process if a patient misses or cancels their appointment?

If your patient needs to change or cancel their appointment, they should phone the service on (02) 9382 0422.

We will contact you if your patient misses or cancels their appointment, with a plan to reschedule as appropriate. 

We are a Medicare service. You must provide a referral that is addressed to one of our Specialist team. Your patient will be bulk-billed.