Supportive Care Service (SCS) - for Health Professionals

Our Services:

The Supportive Care Service (SCS) is for people with a life-limiting or progressive illness. The clinic offers management of complex pain or symptoms, associated with the life -limiting illness, requiring specialist multidisciplinary team management, and assistance with goals of care. This could include management of nutrition, swallowing, communication, mobility, facilitating referrals or linking to relevant services, and psychosocial and spiritual support.

Supportive Care Service flyer.

Our clinic is located in Room 6, 4 North, Tower Block Building,  
Gray Street, St George Hospital   
 
Refer to our campus map.

Clinic Name Clinic Day Clinic Time
St George/Sutherland Supportive Care Service (SCS)  Tuesday 8.00 am - 4.30 pm

Patients will first see Dr Isuru Ratnayake our specialist doctor and Monita Mesuria our Clinical Nurse Consultant. Patients will also see other health professionals from our team. Depending on availability there may be other health professionals present at patient appointments.
 

We are a team of different health professionals including doctors, nurses and allied health professionals including dietetics, occupational therapy, pharmacy, physiotherapy, psychology, social work and speech pathology.

Palliative Care Specialist
Community Supportive Care Specialist  Dr Isuru Ratnayake
Nursing
Clinical Nurse Consultant Monita Mesuria
Allied Health
Dietitian TBA
Occupational Therapist  Ashlee Meades
Pharmacist Sarah Watson
Physiotherapist Sharon Power
Psychologist TBA
Social Worker TBA
Speech Pathologist Val Maynes
Administration Pauline Barker

Inclusion Criteria:

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

  1. Must be over 18 years of age  
  2. Must have a diagnosis of a non-malignant life-limiting illness (see below for disease specific triggers) 
  3. Must live within St George and Sutherland area
  4. Must have a medical referral from a GP or specialist involved in their care 
  5. Must require input from medical and at least one other member of the Multidisciplinary team 
  6. The answer to the surprise question is 'No' (below)

    Surprise Question: Would you be surprised if the patient died in the next 12 months?

    • The 'surprise question' is a prognostic screening tool used to identify people who are at high risk of dying within one year
    • If response is 'No, I would not be surprised', a patient is considered to be in their last 12 months of life
  7. A patient must fit at least ONE of following the general triggers
    • Complex and increasing symptom burden
    • Persistent symptoms, despite optimal treatment of underlying condition(s)
    • Deterioration in functional performance status and increased support needs
    • Patient requires advanced care planning
    • Progressive weight loss of more than 10% dry body mass, in last 6 months
    • Two or more unplanned acute admissions in last 12 months
    • Patient or family requesting supportive and/or palliative care input

Disease Specific Triggers

In addition to at least one general triggers, there may be disease specific triggers as outlined below. These are a guide only to prompt clinicians to consider their patient may be approaching end of life and be appropriate for referral to End of Life and Palliative Care Services.

Cohort Triggers
Cardiac/vascular disease
  • NYHA class IV heart failure, severe valve disease, or extensive coronary artery disease
  • Breathless or chest pain at rest or on minimal exertion in spite of maximal therapy
  • Scoring severe or overwhelming on IPOS
  • Severe and inoperable symptomatic vascular disease

Respiratory

  • Scoring severe or overwhelming breathlessness on IPOS
  • Progressive respiratory failure /difficult to control breathlessness
  • Increased frequency of exacerbations (more than 3 in 12 months)
  • More than 6 weeks of systemic steroids for COPD in preceding 6 months
  • Progressive escalation in NIV settings/usage
  • Symptomatic right heart failure
  • Fulfils long term oxygen therapy criteria

Liver

  • Advanced cirrhosis with one or more complications: intractable ascites, hepatic encephalopathy, hepatorenal syndrome, bacterial peritonitis, recurrent variceal bleeds
  • Serum albumin <25 g/l, and prothrombin time raised or INR prolonged
  • Hepatocellular carcinoma
  • Not a candidate for a Liver transplant
Neurodisability
  • Aspiration pneumonia 
  • Progressive respiratory failure 
  • Progressive breathlessness 
  • New onset or worsening communication, speech and/or swallowing problems 
  • Emerging cognitive difficulties
Renal
  • We will accept patients with end stage renal failure if they have at least one other significant co-morbidity (e.g. cardiac failure, respiratory failure) 

 

Exclusion Criteria:

List of Exclusion Criteria for SCS Instead consider
Actively dying  Refer patient to the local Palliative Care Community (CPCT) 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 readdress 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 the appropriateness of such a referral.

If your patient is eligible for treatment, please use this referral form.

Email the referral form to: SESLHD-StGeorgeSCS@health.nsw.gov.au

All mandatory information must be complete. The referral form ensures that you do not miss any important information to enable a timely and appropriate referral. You may be contacted requesting a review of your referral if any of the following information is missing.

Important points:

  • You must address the referral to the 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 prior to the appointment date.

We cannot process your referral if it does not meet the above criteria prior to your patient's initial appointment.

Who will contact your patient to schedule an appointment?

We will notify your patient and/or their carer by phone once we have received your referral.

We will send your patient a phone and/or SMS reminder 5 days before their appointment and a phone call the day before their appointment.

You may contact (02) 9113 4182 to follow up on a referral, change an appointment, or cancel.

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 our specialist doctor. Your patient will be bulk billed.