Southcare Outreach Service (SOS)
The SOS is a multidisciplinary rapid response community team for the ageing population over 65 years* or
- > 50 years for the Aboriginal and Torres Strait Islander population.
- > 16 years for clients referred by the RADIUS unit.
- > 18 years for clients referred by TSH HITH for allied health requirements.
The SOS provides short term acute and sub-acute clinical interventions for a maximum of six weeks. The aim of the SOS is to provide safe and effective interventions to allow clients at risk of presenting or re-presenting to the Emergency Department (ED)/ Hospital to remain at home. The SOS integrates and coordinates clients care with their GP and executes care plan requirements including referral on to services to ensure clients can remain safe at home.
The multidisciplinary team includes: Nursing, Physiotherapy, Occupational Therapy, Social Work and Geriatrician’s working in partnership with General Physicians (GPs).
-34.038246574702, 151.11341342925
Clients suitable for referral to the Southcare Outreach Service:
- Reside in the Sutherland Shire catchment area.
- Are over 65 years* or
- > 50 years for the Aboriginal and Torres Strait Islander population.
- > 16 years for clients referred by the RADIUS unit.
- > 18 years for clients referred by TSH HITH for allied health requirements.
- Are at risk of presenting to ED or re-presenting to ED within the next 48 hours.
- Have goals that can be addressed by a multidisciplinary team in the client’s home.
Exclusion Criteria:
The following clients are excluded:
- Clients admitted in Hospital. Referrals are not taken for admitted in-patients. Referrals are only taken for clients being discharged from the Emergency Department, short stay unit, HITH or RADIUS unit.
- Clients residing care in a Residential Aged Care Facility.
General Practitioners, Staff specialists such as Geriatricians, Emergency Department staff, Aged Care Services Emergency Team (ASET) staff, RADIUS staff, HITH staff, NSW Ambulance Service, NSW Police, clients and carers as well as Southcare and community services can refer.
- Electronic Medical Record (eMR) referral (TSH) Southcare Community or
- Fax an Access and Referral Intake Form to (02) 9540 7869 or
- Scan and email an Access and Referral Intake Form to SESLHD-SouthCareIntake@health.nsw.gov.au or
- Phone SOS triage Nurse on 0410 550 867.
All referrals are considered URGENT and are seen within 48 hours of referral being accepted.
The SOS offers a seven day per week service:
0800 - 1900 hours Monday - Friday.
0800 - 1830 hours Saturday and Sunday, including public holidays.
Nil
Please let us know if you need an interpreter. You can contact us by telephoning the Translating and Interpreting Service (TIS) on 131 450. Tell the operator what language you speak, and then ask the interpreter to set up a telephone conversation between you, an interpreter, and us on 0410 550 867.
Social Work and Welfare Officer
Southcare Social Workers assist people and/or their carers who have complex health and psychosocial issues and/or ageing related illnesses that impact on their ability to live independently in the community. Social Workers work within a strengths-based and reablement model. Social work provides consultation, comprehensive assessment and link people to community supports as needed. Social work can also assist and advise with issues such as: guardianship and financial management, suspected abuse of older persons, dementia/cognition and capacity concerns, and hoarding and squalor.
Consultation to other professionals within Southcare, TSH and the general community is also provided.
The Welfare Officer assists with facilitating the provision of formal services or residential aged care placement/respite through referral, advocacy and case management, if there is not a suitable family/carer/friend to assist.
Hours/Days of Operation:
8.00am - 4:30pm
Monday to Friday
-34.038246574702, 151.11341342925
A resident of the Sutherland Shire who is needing and eligible for social work services as outlined above.
Residents and/or carers of the Sutherland Shire (aged over 65 years or over 50 years for Aboriginal and Torres Strait Islander population) who have complex health and psychosocial issues that impact on their ability to live independently in the community. Consideration will be given to younger clients with ageing related illnesses. Complex psychosocial issues may include;
- Guardianship and financial management
- Concerns around abuse
- Dementia/cognitive capacity concerns
- Carer stress
- Hoarding and squalor
Exclusion Criteria: People whose primary issue relates to mental health, alcohol and other drugs, or intellectual disability
- Electronic Medical Record (eMR) referral (TSH) Southcare Community or
- Fax an Access and Referral Intake Form to (02) 9540 7869 or
- Scan and email an Access and Referral Intake Form to SESLHD-SouthCareIntake@health.nsw.gov.au
All referrals are prioritised and allocated according to need.
Nil.
Please let us know if you need an interpreter. You can contact us by telephoning the Translating and Interpreting Service (TIS) on 131 450. Tell the operator what language you speak, and then ask the interpreter to set up a telephone conversation between you, an interpreter, and us on 9540 7540.
Respiratory Coordinated Care Program (RCCP)
The Respiratory Coordinated Care Program (RCCP) is a community-based respiratory multidisciplinary team that provides home monitoring, education and specialised nursing and physiotherapy care, to people with chronic lung conditions who live in the Sutherland Shire.
The aim of the program is to integrate and coordinate services between hospital, GP’s and Specialists for patients with complex respiratory disorders; assisting them to optimise their function and quality of life at home.
-34.038246574702, 151.11341342925
People with chronic lung conditions who live in the Sutherland Shire.
A client that:
- Is a resident of the Sutherland Shire.
- Requires home monitoring, assessment, physiotherapy (chest and/or physical activity interventions), and education to enable self-management of their chronic lung condition, particularly after a recent admission to hospital or presentation to emergency, to reduce their risk of representing to hospital due to their respiratory condition.
- Would benefit from supervision to facilitate adherence to medical management (e.g. Prednisone doses) which may have changed or modified whilst in hospital or after presentation to emergency department for an exacerbation of their respiratory condition. Examples are infective exacerbation of COPD, Pneumonia/LRTI, Interstitial Lung disease.
Mark attention RCCP.
Referrals accepted from Respiratory Specialists and GPs.
For administration of medications, a medication authority form must be completed.
- Electronic Medical Record (eMR) referral (TSH) Southcare Community or
- Fax an Access and Referral Intake Form to (02) 9540 7869 or
- Scan and email an Access and Referral Intake Form to SESLHD-SouthCareIntake@health.nsw.gov.au
No.
URGENT referrals seen within 48 hours.
NON-URGENT referrals seen within 1 week.
A prioritisation tool is utilised to triage referrals.
Prioritisation is given to clients who are at risk of deterioration and hospitalisation.
8.00am - 4:30pm
7 days/week nursing service; Mon, Tues, alternate Wed physiotherapy service
Nil.
Please let us know if you need an interpreter. You can contact us by telephoning the Translating and Interpreting Service (TIS) on 131 450. Tell the operator what language you speak, and then ask the interpreter to set up a telephone conversation between you, an interpreter, and us on 9540 7540.
Pulmonary Rehabilitation Gym
An 8-week, twice a week multidisciplinary group gym exercise and education program to improve exercise capacity and quality of life, and to enable self-management, for people with chronic respiratory disease and for people prior to and post lung surgery/transplant.
Oxygen may be provided in the gym for exercise if needed.
-34.038246574702, 151.11341342925
Those with chronic respiratory disease and for people prior to and post lung surgery/transplant.
A client that:
- Is a resident of the Sutherland Shire
- Has a chronic respiratory condition, is for lung surgery or has had recent lung surgery
- Has the ability to follow instructions
- Has the ability to use some gym equipment
- Is motivated to continue an independent exercise regime at home
Exclusion Criteria:
- Severe cognitive impairment
- Blind
- Infection that places other participants at risk
- People unable to walk independently (with or without walking aid)
- If modified exercise is likely to exacerbate conditions
- Has completed the program within the last 2 years
Mark attention Pulmonary Rehabilitation.
Referrals accepted from any healthcare provider.
- Electronic Medical Record (eMR) referral (TSH) to Southcare Community or
- Fax an Access and Referral Intake Form to (02) 9540 7869 or
- Scan and email an Access and Referral Intake Form to SESLHD-SouthCareIntake@health.nsw.gov.au
A prioritisation tool is utilised to triage referrals. Priority is given to clients with a recent history of lung surgery or hospital admission for COPD exacerbation, or for lung surgery/transplant work up.
Those who have completed the program within the last 2 years will not be accepted.
Donations towards gym equipment are welcome.
Limited bus transport to and from the outpatient gym is available for residents of the Sutherland Shire at a cost of $5 per session.
Assessments run via telehealth & clinic
Clinic days: Wednesday & Thursday
Exercise groups run 11:30am - 3:30pm Tuesday & Friday
Please let us know if you need an interpreter. You can contact us by telephoning the Translating and Interpreting Service (TIS) on 131 450. Tell the operator what language you speak, and then ask the interpreter to set up a telephone conversation between you, an interpreter, and us on 9540 7540.
Physiotherapy
The Physiotherapy Service provides a Short-Term home visiting service for housebound elderly and disabled residents of the Sutherland Shire over the age of 65.
Physiotherapy treatment is provided for:
- Rehabilitation after a recent operation
- Mobility assessment and to determine need for walking aids
- Exercise program assessment and prescription
Hours/Days of Operation:
8.00am - 4:30pm
Monday to Friday
-34.038246574702, 151.11341342925
An elderly or disabled resident of the Sutherland Shire over the age of 65 needing a short-term home visiting physiotherapy service.
A client that is:
- 65 years or older
- A resident, or residing with a resident, of the Sutherland Shire
- Housebound / unable to access outpatient physiotherapy
Exclusion Criteria:
- People under 65 years of age
- People living in aged care facilities with physiotherapy services
- Third party, insurance, or NDIS clients
- DVA Gold Card holders
- People who can access outpatient or private physiotherapy (e.g. Home care package Level 3 or 4)
Mark attention Southcare Physiotherapy.
Referrals accepted from any healthcare provider.
- Electronic Medical Record (eMR) referral (TSH) Southcare Community or
- Fax an Access and Referral Intake Form to (02) 9540 7869 or
- Scan and email an Access and Referral Intake Form to SESLHD-SouthCareIntake@health.nsw.gov.au.
A prioritisation tool is utilised to triage referrals.
Nil
Please let us know if you need an interpreter. You can contact us by telephoning the Translating and Interpreting Service (TIS) on 131 450. Tell the operator what language you speak, and then ask the interpreter to set up a telephone conversation between you, an interpreter, and us on 9540 7540.
Pharmacist
The Pharmacist provides:
- Medication reconciliation and confirmation of a patient’s current medication list.
- Assessment of clients or their carer’s ability to handle and administer medication.
- Assistance for clients who are taking multiple medications or who have a difficult regime to follow (e.g. webster packs, provision of medication lists, medication rationalisation).
- Education for clients and their carers about medication and the importance of compliance.
- Clinical review of medications and monitoring for adverse effects.
- Follow-up post discharge from hospital to ensure continuity of medication.
- Liaison with relevant professionals to ensure continuity of medication and medication optimisation (e.g. general practitioner, community pharmacy, specialists, etc).
Hours/Days of Operation
8.00am - 4.30pm
Monday to Friday
-34.038246574702, 151.11341342925
Sutherland Shire residents who are living at home and at risk of hospital admission due to medication misadventure.
A resident of the Sutherland Shire (or residing with) who are:
- Living at home.
- Having problems with polypharmacy, pill burden, compliance issues, complicated directions for medications, (e.g. reducing doses of steroids, newly commenced on anticoagulant).
- At risk of hospital admission due to medication-related incidents, (e.g. falls).
- Taking medications with concerns of drug interactions, swallowing difficulties, etc.
- Requiring medication optimisation and/or rationalisation.
Persons under 65 years:
- Electronic Medical Record (eMR) referral (TSH) or
- Fax an Access and Referral Intake Form to (02) 9540 7869 or
- Scan and email an Access and Referral Intake Form to SESLHD-SouthCareIntake@health.nsw.gov.au
Persons 65 years and over:
Online at My Aged Care www.myagedcare.gov.au or phone 1800 200 422. Ask to be referred to Southcare Community Services - Service Type – Pharmacist.
Referral priorities exist and all referrals will be prioritised according to clinical need.
Nil
Please let us know if you need an interpreter. You can contact us by telephoning the Translating and Interpreting Service (TIS) on 131 450. Tell the operator what language you speak, and then ask the interpreter to set up a telephone conversation between you, an interpreter, and us on 9540 7540.
Occupational Therapy
Occupational Therapists provide services for the aged and younger people with chronic medical conditions in the Sutherland Shire with the aim of optimising function and maintaining the client in their home. This involves the assessment of the client in the home, prescription of equipment and home modifications and referral to community and other Southcare services.
Hours/Days of Operation
8.00am - 4.30pm Monday to Friday
-34.038246574702, 151.11341342925
A resident of the Sutherland Shire needing Occupational Therapy services.
A resident of the Sutherland Shire (or residing with) who are aged or younger, physically disabled of 18 years of age and over, and who have the potential to remain in their own home.
Exclusion Criteria:
- People living in a nursing home.
- Third party insurance clients.
- DVA Gold Card Holders.
- NDIS clients.
- People receiving a Home Care Package Level 3 or 4.
Persons under 65 years:
- Electronic Medical Record (eMR) referral (TSH) or
- Fax an Access and Referral Intake Form to (02) 9540 7869 or
- Scan and email an Access and Referral Intake Form to SESLHD-SouthCareIntake@health.nsw.gov.au
Persons 65 years and over:
Online at My Aged Care www.myagedcare.gov.au or phone 1800 200 422. Ask to be referred to Southcare Community Services - Service Type – Allied Health Occupational Therapy.
Yes – this can vary, contact Occupational Therapy to enquire if necessary.
All referrals are prioritised and allocated according to their functional need.
URGENT referrals are usually seen within 1-2 weeks.
Nil
Please let us know if you need an interpreter. You can contact us by telephoning the Translating and Interpreting Service (TIS) on 131 450. Tell the operator what language you speak, and then ask the interpreter to set up a telephone conversation between you, an interpreter, and us on 9540 7540.
Mobility Group Exercise Class
The Mobility Group is a once a week for 8 consecutive weeks group exercise and education program for individuals aged 65 years and older who have experienced a decline in their mobility. It is designed to improve their physical function and reduce risk of falls. Clients may be using a walking frame or walking stick.
Clients will have their gait analysed and lower limb strength and balance tested. An individualised home exercise program to improve lower limb strength and balance is provided to participants.
At the end of the Mobility Group program, clients are encouraged to continue their exercise regime at home and/or join a community-based exercise group for long-term maintenance of activity
Hours/Days of Operation
10:00am - 11:00 am Thursday and Friday
-34.038246574702, 151.11341342925
A resident of the Sutherland Shire aged 65 years and older who has experienced a decline in their mobility.
A person that has mobility issues and:
- Is a resident of the Sutherland Shire and aged 65 years or older
- Has a cognition level suitable to engage in the program
- Able and willing to exercise in a small group setting
- Is motivated to continue an exercise regime at home
- Has a goal of participating in a community-based outside activity
Exclusion criteria:
- People living in aged care facilities who have access to their own physiotherapist
- Third party, insurance, or NDIS clients
- People who are currently accessing external community exercise programs
- People who require constant 1:1 supervision
People unable to walk independently (with or without walking aid)
Mark attention MOBILITY GROUP.
Referrals accepted from any healthcare provider.
Must complete an Access and Referral Form
- Electronic Medical Record (eMR) referral (TSH) to Southcare Community
- Fax Access and Referral Form to (02) 9540 7869 or scan and email to SESLHDSouthCareIntake@health.nsw.gov.au
A prioritisation tool is utilised to triage referrals.
Priority is given to clients with a recent history of falls.
Donations towards gym equipment are welcome.
Limited bus transport to and from the program is available for residents of the Sutherland Shire at a cost of $5 per session.
Please let us know if you need an interpreter. You can contact us by telephoning the Translating and Interpreting Service (TIS) on 131 450. Tell the operator what language you speak, and then ask the interpreter to set up a telephone conversation between you, an interpreter, and us on 9540 7540.
Geriatricians
The Geriatrician service provides:
- Medical consultation and management.
- Psychogeriatric consultation and management.
Hours/Days of Operation
8:00am - 4:30 pm Monday to Friday
-34.038273191814, 151.11339737158
Must be referred by a GP or medical officer.
A person with aged care illnesses requiring a medical or Psychogeriatric consult.
A referral letter from a GP or Specialist must be received by the clinic in advance of the scheduled appointment either by fax or in person on the day and must include the following:
- Name of the specific geriatrician, date of referral, GP or Specialists name, practice, provider number and signature
- Name, address, date of birth of patient, Medicare and/or DVA number, country of birth and if an interpreter is required.
- Reason for referral.
- Relevant medical history.
- Current medications.
- Recent pathology or x-ray results.
Exclusion Criteria:
People requiring social or functional assessment without the need for a medical Psychogeriatric or general Aged Care Assessment should be referred to Southcare indicating service/s required.
Fax a letter of referral [must indicate if URGENT] to (02) 9540 7870
Email a referral to SESLHD-Geris@health.nsw.gov.au
By phone (02) 9540 7109
4 to 8 months waiting list.
However, URGENT clients will be seen earlier.
Medicare bulk billed.
Please let us know if you need an interpreter. You can contact us by telephoning the Translating and Interpreting Service (TIS) on 131 450. Tell the operator what language you speak, and then ask the interpreter to set up a telephone conversation between you, an interpreter, and us on 9540 7109
Geriatric Flying Squad (Southcare)
The Geriatric Flying Squad is a rapid response outreach service into Sutherland Shire Residential Aged Care Facilities (RACFs).
Clients suitable for referral to the Geriatric Flying Squad (GFS) are from Residential Aged Care Facilities (RACF) in the Sutherland Shire local government area who are acutely unwell.
Common conditions GFS can assist with include:
- Pneumonia Community acquired and suspected aspiration pneumonia
- Delirium (i.e. acute change or fluctuation in cognition and/or behaviour)
- Fevers/Infections (i.e. urosepsis, cellulitis or sepsis of unknown origin)
- Acute exacerbations of chronic conditions/symptoms (i.e. heart failure, lung conditions)
- Outbreak management (i.e. gastroenteritis, influenza) – proactive symptom management and support to RACF (Residential Aged Care Facility)
- Terminal palliation following acute deterioration
- Acute conditions where preference is to avoid hospital presentation/admission and focus of care is on conservative management in the RACF
Hours/Days of Operation
8:00am - 10:00pm Monday to Sunday
-34.038246520014, 151.11341346483
A person who:
1. Is living in a Sutherland Shire RACF.
2. Has an acute deterioration.
3. Hospital transfer is being considered.
4. Has consent of GP (or GP uncontactable/unavailable and client/family consent for referral obtained)
Exclusion Criteria:
1. Residents residing in RACFs outside of the Sutherland Shire LGA
2. GP, resident or family decline Geriatric Flying Squad service
3. Where the condition requires a response in less than 2 hours (NB: GFS response time is 2- 12 hours)
4. Clients with acute cardiac event or haemorrhage or surgical problem for active treatment (referrals for same may be accepted if client is on palliative care/approaching end of life and hospital avoidance is preferred and acute symptom management is needed)
5. Transfusions of blood or blood related products
6. Ongoing chronic issues requiring a long-term input and management plan (i.e. no current acute concern)
7. Community members residing in Independent Living Units (ILUs) or group homes
- By phone 0419 382 406
- Fax a Geriatric Flying Squad referral form/checklist to (02) 9540 7869.
- Electronic Medical Record (eMR) referral (TSH)
The Geriatric Flying Squad service accepts referrals from General Practitioners, Residential Aged Care Facility staff, NSW Ambulance service and TSH Emergency Department staff.
Nil
Please let us know if you need an interpreter. You can contact us by telephoning the Translating and Interpreting Service (TIS) on 131 450. Tell the operator what language you speak, and then ask the interpreter to set up a telephone conversation between you, an interpreter, and us on 0419 382 406.