Supportive Care Service (SCS) - for Health Professionals

Room 5, 4 North, Tower Block Building, 
Gray Street, St George Hospital, 2217
 
Refer to our campus map.

Clinic Name	Clinic Day	Clinic Time
St George Care Service	Tuesday	8.00 am - 4.30 pm

Palliative Care Specialist
Supportive Care Specialist	Dr Clare Jones Locum for  Dr Isuru Ratnayake
Nursing
Clinical Nurse Consultant	Monita Mesuria
Allied Health
Dietitian	Jade Kearsey
Occupational Therapist	Jacqueline Burgess
Pharmacist	Irene Stafidas
Physiotherapist	Sharon Power
Psychologist	Ieva Zakrevska
Social Worker	Rebecca Thornley
Speech Pathologist	Val Maynes
Administration
Jo Conn

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 life-limiting illness with a prognosis of 12-24 months (see below for disease specific triggers) 
3. Must live within St George 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)  If they do not have renal physician and have a 12–24-month prognosis
Primary Brain Tumour	Functional decline   Symptomatic from illness   Limited supports in the community
Malignant Illness	Must be known to a Palliative care specialist prior to acceptance in SCS service.   Must have stable metastatic disease   Must have 2 or more Allied health requirement to be referred to supportive care service.   Accept referral from in June 2025

 

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
• The referral should be an “indefinite” referral. 
• 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?

CNC 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 your 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.