/ CHHS16/005

Canberra Hospital and Health Services

Operational Procedure

Community CareProgram Referral Management

Contents

Contents

Purpose

Scope

Section 1 – Referrals, eligibility criteria and prioritisation

Referrals

Eligibility criteria

Prioritisation

Section 2 – Referral management

Implementation

Related Policies, Procedures, Guidelines and Legislation

Search Terms

Attachments

Attachment 1 - Community Nursing eligibility criteria and prioritisation examples

Attachment 2 – Nutrition Service eligibility criteria and prioritisation examples

Attachment 3 – Occupational Therapy Service eligibility criteria and prioritisation examples

Attachment 4 – Physiotherapy Service eligibility criteria and prioritisation examples

Attachment 5 – Podiatry Service eligibility criteria and prioritisation examples

Attachment 6 – Social Work Service eligibility criteria and prioritisation examples

Purpose

This document outlines operational procedures for the management of referrals to Community Care Program allied health and nursing services. It also defines eligibility and prioritisation criteria for each discipline.

Referrals to Community Care services are accepted from health professionals and any other person in the community.Self referrals are also accepted.

Scope

Community Care Program (CCP) services include: Community Care Physiotherapy, Nutrition, Occupational Therapy, Podiatry, Social Work and Community Nursing.

This procedure applies tostaff in the Community Care Program andCommunity Health Intake (CHI).

This procedure can be used by staff in the Community Care Program and Community Health Intake to inform referring parties of the processes for referral.

Section 1 –Referrals, eligibility criteria and prioritisation

Community Care services are generally provided in health centre clinics. With the exception of CCP Podiatry, a home service is provided for those patients who, for medical reasons, are unable to attend a clinic appointment,or where assessment/treatment is more appropriately provided in the home environment.

Where an environmental assessment of the home has determined that care cannot be provided safely in the home, other ways of providing the service will be considered in consultation with the patient and the manager(for further information see: Providing Clinical Health Services in an Off Campus Environment Procedure).

Referrals

Verbal consent from the patient must be sought prior to the referral being made.

Referral forms must be completed in full and must clearly identify the referring person’s name and contact details. The reason for referral or service requested should be clearly documented. Where applicable, treatment and medication orders must be attached.

All referrals must be made through Community Health Intake via:

  • Telephone - 6207 9977or
  • Fax- completed CHI Referral Formto 6205 2611 or
  • Email - completed CHI Referral Form to

Note:Patients who are eligible forthe Commonwealth Home Support Program (CHSP) must be directed to the My Aged Care portal if they are referring for community nursing, occupational therapy, podiatry and physiotherapy services. CHI will receive or retrieve the referrals from the My Aged Care portal, check they meet service criteria, allocate initial priority and make appointments where required.

Referrals within Community Care (for example from one CCP discipline to another CCP discipline) will also need to go through CHI (and if applicable via My Aged Care portal), with the exception of referrals between CCP Podiatry and CCP Footcare.

Eligibility criteria

To be eligible for Community Care services patients must have either a permanent,or temporary,Australian Capital Territory (ACT) residential address as registered in the patient administration system (ACTPAS).

Community Care does not provide clinical services to residents of Residential Aged Care facilities. Clinical Nurse Consultants/Clinical Specialists can provide consultancy services to these facilities. Patients in independent living units within retirement villages are eligible for Community Care services.

Eligibility criteria for each discipline are outlined in attachments (see attachments 1-6).

Eligibility criteria are communicated to CHI (via scripting). The service manager reviews the scripting regularly and informs CHI of any changes. Significant changes to scripting, such as where eligibility or access will be affected, will need to be discussed with and approved by the CCP Allied Health Services or CCP Nursing Services Manager.

If patients are eligible for the National Disability Insurance Scheme (NDIS), the requested service can be provided; however, the funding for this service will now come from the NDIS. The service needs to be included on the patient’s Plan so RACC can bill the National Disability Insurance Agency for the service.

Patients not eligible for Community Care services are advised to seek private services.

Prioritisation

Each referral is prioritised, and a time frame for first intervention is allocated based upon clinical need. Priority is entered into ACTPAS as a category, as follows:

  • For allied health services:
  • Category 2a – to be seen within 2 working days
  • Category 2 – to be seen within 10 working days
  • Category 3 – to be seen within 50 working days
  • For nursing services:
  • Category 2a – to be seen within 24 hours
  • Category 2 – to be seen within 2 working days
  • Category 3 – to be seen within 14 days

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Section 2 – Referral management

The date of the referral is the date it is created in ACTPAS and should not be backdated.

  1. CHI nursing staff create an ACTPAS referral and prioritise according to the clinical information that is provided at that time.
  2. CHI nursing staff allocate the referral to the appropriate discipline/regional team.
  3. If applicable to the service, CHI then allocate an appointment time.Note: ifCHI staff cannot find an appointment within the recommended timeframe, CHI will notify the service (via email to manager and generic inbox).
  4. Each discipline/team has a designated staff member(s) who checks and actions referrals. This staff member:
  • amends the prioritisation category if required
  • ensures that a contact, or appointment has been made within the designated prioritisation category timeframe
  • allocates the referral to a clinician/team where necessary.
  1. Referrals to community nursing on weekends (from 1600hrs on Friday until0800hrs on Monday) and public holidays must be faxed or scanned to the Link team (After Hours community nursing).
  • Referrals are triaged, the referrer must phone the Link After Hours Coordinator on 0417 434 990 and discuss the referral.
  • If the referral is appropriate for After Hours services, the referrer must fax the completed referral form to the Link team on 6205 2829 and to CHI on 6205 2611.

CHI will create a referral to Link if the service commences on the weekend.

Note:If the patient requires an interpreter,the staff member who makes the appointment must also book the interpreter. This can be CHI staff, Health Centre (HC) Administration staff, or clinical staff.When a staff member reschedules a service, the staff member must also reschedule the interpreter booking.

Note: Patients should only have one referral open to the service.Where CHI receives a new referral request and there is an existing referral to the specified service in ACTPAS, CHI will add thisinformation to the current open referral, or contact the service manager to discuss. It is not the responsibility of CHI to close referrals.

Where a new referral is received by the service and a referral is still open in ACTPAS, it is the responsibility of the service to manage the referral.

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Implementation

This procedure is available to all ACT Health staff on the ACT Health Policy Register.

This procedure will be communicated to Community Care staff at team meetings. New staff will be educated on the referral management procedures through existing orientation programs.

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Related Policies, Procedures, Guidelines and Legislation

Legislation

Health Professionals Act2004

Health Records (Privacy and Access) Act1997

Policies and Procedures

Providing Clinical Services in an Off Campus Environment Procedure

Clinical Records – Records Management Manual

Administrative Records Management Policy

Clinical Records – Release or Sharing of Clinical Records or Personal Health Information Procedure

Consumer Feedback Management Policy and Procedure

Community Based Clinical Records Procedure

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Search Terms

Community Care Program, Community Health Intake, CHI, Referral, Eligibility, Prioritisation

Community Nursing, Nutrition, Occupational Therapy, Physiotherapy, Podiatry, Social Work

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Attachments

Attachment 1 - Community Nursing Service eligibility criteria and prioritisation

Attachment 2 - Nutrition Service eligibility criteria and prioritisation

Attachment 3 - Occupational Therapy Service eligibility criteria and prioritisation

Attachment 4 - Physiotherapy Service eligibility criteria and prioritisation

Attachment 5 - Podiatry Service eligibility criteria and prioritisation

Attachment 6 - Social Work Service eligibility criteria and prioritisation

Disclaimer: This document has been developed by ACT Health, <Name of Division/ Branch/Unit> specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended / Section Amended / Approved By
7 March 2016 / Section 1 – paragraph added to include reference to NDIS / Policy Team Leader

Attachment 1 - Community Nursing eligibility criteriaand prioritisation examples

Community Nursing Services include:

  • Wound management and nurse practitionerreview clinic
  • Continence and urinary catheter management
  • Primary palliative care
  • Post chemotherapy support, management of central venous access devices
  • Drain management
  • Support with self management of gastrostomy, Home Parenteral Nutrition, cervical collar and tracheostomy
  • Stoma clinic , pre and post operative education
  • Self Management of Chronic Conditions courses
  • Education and short term monitoring of bloodpressure, blood glucose levels, medicationadministration.

Referrals for short term administration of antibiotics via intramuscular route are accepted. Community nursing accepts referrals for administration of antibiotics via central venous access device only if the patient is under the care of a medical specialist in the ACT.

Community nurses do not accept referrals for administration of antibiotics via cannula or butterfly device.

Community nurses do not administer the first dose of each course or episode of the following medications: any parenteral antibiotic, any intravenous medication, insulin, injectable anticoagulants, chemotherapy agents, biological modifiers.

Not eligible for services:

  • Residents in Residential Aged Care facilities.

Note: Clinical Nurse Consultants/Clinical Specialists can provide consultancy services to these facilities.

Department of Veterans Affairs (DVA) cardholders: DVA Gold card holders are eligible for DVA provider services. Referrers should seek the services of a private provider in the first instance. The Yellow Pages directory or DVA will provide details of private service providers.

Patients with the intent to claim for Third Party Liability or Worker’s Compensation (or who’s claim has not been approved) are eligible for the service should they wish not to attend a private nursing service. They are advised that their insurer will be invoiced in the event that their claim is approved or upon settlement of the case.

Prioritisation examples

Category 2a / Examples include:
  • Post chemotherapy monitoring -completion of first cycle
  • Syringe driver management
  • Severe constipation (administration of fleet or other enema)
  • Acute pain control including administration of Schedule 8 and Schedule 4 medications
  • Routine control of vomiting and administration ofantiemetic
  • Administration of medications such as eye drops, biological modifiers, intravenous antibiotics and anticoagulants as ordered by medical officer
  • Post insertion of Peripheral Inserted Central Catheter (PICC)
  • Blood glucose monitoring/insulin administration and education (short term)
  • Wound care for infected heavily exudating wounds or as ordered by medical officer
  • Drain care where nurse assistance is required
  • Vacuum Assisted Closure (VAC) dressings
  • Tracheostomy/laryngectomy tube monitoring
  • Chest drain monitoring.

Category 2 / Examples include:
  • Routine post chemotherapy monitoring
  • Central Venous Access Device (CVAD) maintenance and monitoring
  • Routine bowel management (short term enema/suppository administration, laxative advice)
  • Non daily (not infected or heavily exudating) wound dressing
  • Catheter, stoma and gastrostomy tube management and education
  • Short term monitoring of blood pressure
  • Routine post cardiac surgery monitoring.

Category 3 / Examples include:
  • Routine care of Indwelling Catheter (IDC) or Suprapubic Catheter (SPC)
  • Weekly/fortnightly/monthly injections
  • Removal of surgical clips
  • Continence assessments
  • Stoma review
  • Portacath management.

Attachment 2 – Nutrition Service eligibility criteria and prioritisation examples

Not eligible for services:

  • Third Party Liability or Workers compensation cases should be directed to private providers. These can be found in the Yellow Pages directory.
  • Patients on Home Care Package Level 3 or 4.
  • Residents in Residential Aged Care facilities.
  • Department of Veterans Affairs (DVA) cardholders:

DVA Gold card holders are eligible for DVA provider services. Referrers should seek the services of a private provider in the first instance. The Yellow Pages directory or DVA will provide details of private service providers.

Some people are not eligible for CCPNutritionservices as they can be more appropriately referred to other services. These are:

  • Patients with diagnosed diabetes mellitus (Type 1, Type 2, Gestational Impaired Glucose), Impaired Glucose Tolerance or Impaired Fasting Glucose.

These patients are seen by ACT Diabetes Service Dietitians. The Diabetes Dietitian can refer clients to CCP nutrition groups.

  • Patients with food allergy and complex food intolerances.

These patients are seen by Acute Support Nutrition.

  • Patients with diagnosed eating disorders (Anorexia Nervosa, Bulimia, Eating Disorders Not Otherwise Specified).

These patients may be eligible for services offered by Mental Health (Eating Disorder Program) or will need to access private services.

  • Patients accessing Rapid Assessment of the Deteriorating Aged at Risk (RADAR) or Transitional Therapy Care Program.

These patients are seen by the dietitian assigned to these programs.

  • Patients undergoing haemodialysis at Canberra Community Dialysis Centre (CCDC), Acute Dialysis unit Canberra Hospital (Ward 8A), home haemodialysis patients, peritoneal dialysis patients. Note: Community Health Centre dialysis patients are seen by CCP Nutrition.
  • Patients receiving chemotherapy treatment at Canberra Hospital.

These patients are seen by Acute Support Nutrition.

Prioritisation examples

Category 2a / Patients receiving enteral nutrition aged ≥ 18 years
Category 2 / Presenting issues include:
  • Malnourished: 5% unintentional weight loss in the last 3-6 months
  • High risk of malnutrition. This may be indicated by: recent unintentional weight loss of 3kg in 3 months, poor appetite or the client looking obviously frail or underweight or body mass index (kg/ m2) <18.5
  • Needing advice/assistance with prescribed nutritional supplements
  • Chronic Obstructive Airway Disease, Heart Failure
  • Palliative care patients
  • Newly diagnosed and active(5-8weeks) minor gastrointestinal disorders (e.g. diarrhoea, diverticular disease, irritable bowel syndrome, reflux, gall bladder disease, stoma, peptic ulcer disease)
  • Diet therapy to decrease blood lipid profile and high blood pressure (medical officer referral for pre-medication diet trial)
  • Nutrient deficiency diagnosed by a medical officer
  • Poor wound healing for newly diagnosed wound (3 months)
  • Poor swallowing (speech pathology referral also indicated)
  • Thickened fluids (speech pathology referral also indicated)
  • Texture modifications (for swallowing issues or gastrointestinal disorders e.g. after bowel obstruction)
  • Advance renal failure with Glomerular Filtration Rate (eGFR) < 30ml/min, those receiving haemodialysis at Belconnen and Tuggeranong Community Health Centres only. Book into renal specific nutrition clinic only.
Note: the above criteria may include patients with conditions listed in Category 3, but presenting issue is in this category i.e. Category 2)
Category 3 / Presenting issues include:
  • General nutrition issues, high fibre, vegetarian/vegan
  • Poor wound healing in long standing wound (> 3 months)
  • Weight management: obesity/ overweight/ binge eating — only offer Adult Healthy Weight Group* (see * on p11)
  • Heart/cardiovascular disease: raised blood lipids, high blood pressure - only offer Heart Fare*(see * on p11)
  • Long standing (> 8 weeks) minor gastrointestinal disorders (e.g.: constipation and diarrhoea, diverticular disease, irritable bowel syndrome, reflux, gall bladder disease, stoma, peptic ulcer disease)
  • Non-alcoholic fatty liver disease (offer Adult Healthy Weight Group)
  • Hepatitis (not cirrhosis) requiring weight reduction (offer Adult Healthy Weight Group)
  • Inflammatory or autoimmune disease: arthritis, gout
  • Neurological disorders: Parkinson's disease, Stroke, Multiple Sclerosis, Motor Neuron Disease (unless malnutrition or poor swallowing – Category 2)
  • Kidney disease: with Glomerular Filtration Rate (eGFR) > 30ml/ min, kidney stones, post renal transplant. Book into general nutrition clinics
  • Polycystic Ovarian Syndrome (PCOS) (no Diabetes).

*For Weight Management and Cardiovascular Disease offer individual appointment only if:

  • the patient has completed appropriate group sessions
  • an interpreter is required
  • behavioural or significant mental health issue is identified
  • disability would affect ability to learn
  • patient has been diagnosed with heart failure by a medical officer
  • medical officer has requested immediate diet therapy prior to administration of medication.

Attachment 3 – Occupational Therapy Service eligibility criteria and prioritisation examples

The Occupational Therapy (OT) service provides prescription of home modification and Assistive Technology (AT) to address issues of home safety and independence for adult patients with physical disabilities.

Not eligible for services:

  • Third Party Liability or Workers Compensation cases should be directed to private providers. These can be found in the Yellow Pages directory.
  • Patients on Home Care Package unless approved by the Regional Assessment Service (RAS) via My Aged Care portal.
  • Residents in Residential Aged Care facilities.
  • Department of Veterans Affairs (DVA) cardholders.

DVA Gold card holders are eligible for DVA provider services. Referrers should seek the services of a private provider in the first instance. The Yellow Pages directory or DVA will provide details of private service providers.