Rapid response services to support older patients
Do you care for older patients (over 65 years of age), living in the community, at risk of deteriorating and presenting to hospital?
Sir Charles Gairdner Osborne Park Health Care Group have rapid response services to support your patients at home.
Frailty Rapid Access Clinic: A geriatrician led, multidisciplinary clinic for older adults at imminent risk of presenting to hospital with geriatric syndromes (e.g. falls, pain, cognitive decline). The patients acute care needs are addressed in the clinic and the team supports access to ongoing health and community care options. Referral via: Central Referral Service: Frailty Rapid Access Clinic
RAILS Rapid Response Team: A nursing and allied health team providing a rapid response service for older adults through home visits and phone consults. This includes providing equipment, urgent nursing and allied health support and linking with services. The team aims to make contact within 48 hours. Referral via HealthLink at railsrrt
Geriatric care navigators: Available to discuss urgent (not emergency) patient concerns and link patients into the most suitable services. Available Monday to Friday, 8am-4pm on 0491 369 932.
Dr Cory Lei
Hospital Liaison GP Sir Charles Gairdner Osborne Park Health Care Group
cory.lei@health.wa.gov.au
June 2024
New Hospital in the Home service commences at Sir Charles Gairdner and Osborne Park Hospitals
To allow for improved patient care and capacity, the Sir Charles Gairdner Osborne Park Health Care Group has started providing care to eligible patients through a Hospital in the Home (HITH) model.
Patients who are assessed as being suitable may be cared for in their own home with hospital level monitoring and services. Clinical governance of these patients will remain with the treating team until they are discharged.
Please note, HITH is not currently open to GP referrals. Patients who are cared for under this service are classified as public inpatients and are therefore not eligible for MBS services for the duration of their care.
ePrescribing at Sir Charles Gairdner and Osborne Park Health Care Group
Prescriptions are being introduced for consenting patients being seen at outpatient clinics and the emergency department at Sir Charles Gairdner and Osborne Park hospitals. The rollout commenced 20 May 2024 for outpatients and will be followed by the emergency department 17 June 2024.
Patients experiencing issues with their ePrescriptions can either call the clinic who issued the prescription via the hospital switchboard (08 6457 3333), or they can submit a query to the Electronic Prescribing Issue Reporting Form
For further information email, nmhs.eprescribing@health.wa.gov.au
Dr Cory Lei
Hospital Liaison GP Sir Charles Gairdner Osborne Park Health Care Group
cory.lei@health.wa.gov.au
Nov 22
OPH Good Living Arthritis Denmark Program
The Osborne Park Hospital (OPH) Musculoskeletal Outpatient Department, is pleased to reintroduce the Good Living Arthritis Denmark (GLA:D) program to its outpatient services. The program strongly endorses exercise, education and weight control in the seven-week program, which consists of 2 x 60-minute education sessions and twelve group exercise sessions.
The program is now available to those living with knee and hip osteoarthritis, who are keen to pursue conservative management of their symptoms. To be eligible for GLA:D, patients need to have a clinical diagnosis of hip or knee osteoarthritis (or imaging supporting this diagnosis) and be:
- Fluent in English
- Able to understand and retain the education given
- Able to commit to attendance
- Not suffering from fibromyalgia or other chronic pain disorders
- Living within the OPH catchment area
The GLA:D program is available at no cost, with a valid GP referral.
Referral into the program can be via CRS (Physiotherapy Dept OPH – GLA:D program) or by fax (6457 8466).
For more information, visit gladaustralia.com.au
Dr Cory Lei
Hospital Liaison GP Sir Charles Gairdner Osborne Park Health Care Group
cory.lei@health.wa.gov.au
October 2022
Rehabilitation Aged care Intervention Liaison Service (RAILS) at OPH and SCGH
The multidisciplinary RAILS team provides a rapid response service for people over the age of 65 through home visits and phone consultations. Under Emergency Department Innovation funding, RAILS has been expanded from servicing OPH catchment to now include SCGH catchment area. The RAILS team aims to initiate contact with clients within 48 hours.
RAILS accepts referrals via HealthLink Connect: railsrrt or Fax: 6457 8263 / 6457 8405.
Case Study – how RAILS can support your vulnerable patients in the community:
Annie is a 78-year-old grandmother living alone in her home and is socially isolated with little contact with her children. She has been receiving visits from support workers through a Commonwealth Home Support Program. Over the last few months, her support workers have been concerned by her declining cognition, dietary intake and hygiene.
While she had been approved for a higher level of care through a Home Care Package, she was not accessing the care as she did not understand what was being offered or how to accept it.
The support workers referred her to the SCGH Rehabilitation Aged care Intervention Liaison Service (RAILS) – which is now available throughout the North Metropolitan area catchment. A social worker from RAILS arranged to visit Annie at her home. When she arrived, she found that her front door was unlocked and Annie had forgotten about the visit. Her fridge was overflowing with food and found that she had not been taking her medications.
Following the initial visit, a physiotherapist and occupational therapist visited Annie and conducted a range of assessments (mobility, falls, functional and cognitive). Based on the assessments and risks of her ongoing situation, the team arranged for her to be seen by a geriatrician in the Frailty Rapid Access Clinic (FRAC) for further cognitive assessment.
The social worker worked with Annie, her next of kin and the service provider to negotiate commencement of a level 3 Home Care Package. Annie’s services increased to include domestic assistance, transport, social support, gardening, home maintenance / modifications, shopping and management of incontinence.
With the commencement of the Home Care Package Annie progressed very well and started to appreciate the services coming in to support her. Annie’s cognition greatly improved with the new supports, and demonstrated an improvement with insight into her care needs at home.
Education was provided to Annie’s next of kin with regards to Enduring Power of Attorney and Guardianship to support Annie now and in the future. Annie will continue to be reviewed by the Memory Clinic at SCGH.
Dr Cory Lei
Hospital Liaison GP Sir Charles Gairdner Osborne Park Health Care Group
cory.lei@health.wa.gov.au
August 2021
SCGH Geriatric Outpatient Clinic Changes
As of Monday 23rd May 2022, SCGH geriatric outpatient clinics will were relocated to OPH, providing a single centre of excellence in the North Metropolitan Area Health Service for geriatric ambulatory care. For patients, this means increased access to staff, resources and therapies. SCGH and OPH medical staff are now combined to ensure patients will see the same exceptional team to provide ongoing care.
SCGH and OPH Consultants will remain available for referrals – please don’t hesitate to contact the team for any patient concerns.
As part of this transition, referrals will need to be sent via the Central Referral Service (CRS). OPH will continue to receive faxed referrals in the short term (until 30 September).
Services available at OPH include:
- General geriatric
- Memory
- Falls
- Continence
- Parkinson’s
- Stroke Rehab
- Frailty Rapid Access Clinic
- Fragile bone Clinic
- Geronto-rheumatology
For further information, please email Dr Kien Chan, Head of Department (Geriatric, Acute and Rehabilitation Medicine) at Kien.Chan@health.wa.gov.au
Dr Cory Lei
Hospital Liaison GP Sir Charles Gairdner Osborne Park Health Care Group
cory.lei@health.wa.gov.au
OPH Rehabilitation Aged care Intervention Liaison Service expands to SCGH
The multidisciplinary RAILS team provides a rapid response service for people over the age of 65 through home visits and phone consultations. RAILS has now been expanded from servicing OPH catchment to include the SCGH catchment area. The RAILS team aims to initiate contact with clients within 48 hours.
The program prevents avoidable ED presentations and admissions by supporting older adults within their home through:
• Provision of services and equipment
• Urgent nursing and allied health support
• Comprehensive multi-disciplinary assessment/care
• Were necessary, arranging planned admissions to non-tertiary hospitals.
RAILS accepts referrals via HealthLink Connect: railsrrt or via fax 6457 8263 / 6457 8405
Dr Cory Lei
Hospital Liaison GP Sir Charles Gairdner Osborne Park Health Care Group
cory.lei@health.wa.gov.au
SCGH and OPH Frailty Rapid Access Clinic
The Frailty Rapid Access Clinics (FRAC) are multidisciplinary clinics that provide rapid access to geriatrician advice, assessment and treatment with the intent of minimising their interaction with the acute hospital sector unless clinically indicated. The clinics are integrated and provide care-coordination across the health service, in partnership with primary and community care providers.
The FRACs will accept referrals from the ED, inpatient wards and GPs to support the patients remaining out of hospital and the ED.
FRAC services the Sir Charles Gairdner Hospital and Osborne Park Hospital catchment area. Referrals can be made via the Central Referral System.
May 2022
Visiting geriatrician outpatient service to SCGH and OPH patients living in residential care facilities
The Geriatrician Residential Outreach (GRO) service welcomes referrals from GPs and NPs who feel their RACF patients would benefit from a geriatrician review. Some common referral indicators are increasing falls, cognitive or behavioural changes, Parkinson’s disease management and medication-related issues. Recent unplanned hospitalisation may be another flag. Family involvement in the visit is always encouraged as goals and direction of care is often part of the picture.
The team aims to see patients within two to four weeks of receiving a referral. Please note that due to current COVID requirements, the service is providing telehealth consultations only. In-person visits will resume when conditions allow.
Referrals can be sent to:
Geriatrician Residential Outreach (GRO)
Geriatrics, Acute and Rehabilitation Medicine (GARM) SCGHOPH
Fax: (08) 6457 8313
Email: OPH.GROReferrals@health.wa.gov.au
The consultants for GRO services are Dr Chermaine Chua, Dr Brendan Foo and Dr Peter Sarkis. They can be contacted via SCGH/OPH switchboard, on 6457 8000, during office hours.
Dr Cory Lei
Hospital Liaison GP Sir Charles Gairdner Osborne Park Health Care Group
cory.lei@health.wa.gov.au
November 2021
SCGH Immunology Clinic Wait List Update
Due to significant demand, the waiting list for Sir Charles Gairdner Hospital Immunology Clinic appointments is extremely long. The Immunology team is making efforts to address this issue as soon as possible but patients with category 2 and 3 problems are still facing an extended time on the waiting list.
SCGH requests that GPs advise patients of an expected delay, prior to referral. Please also discuss other options such as referral to a private Immunologist where possible. Details of private immunologists can be found on the ASCIA website (www.allergy.org.au) under “locate a specialist”.
Patients with anaphylaxis not attributable to an avoidable medication should be prescribed 2 EpiPens while waiting for immunology review, and be provided with an Anaphylaxis Action Plan. Patients are automatically eligible for an authority PBS prescription if they have been discharged from hospital or an emergency department after treatment with adrenaline for acute allergic reaction or if they have previously been issued with an authority prescription for an Epipen. For patients with anaphylaxis who do not qualify under either of these criteria, a PBS authority prescription can be provided in consultation with a clinical immunologist.
Email the Immunology Department at scgh.clinicalimmunology@health.wa.gov.au to assist with endorsing Epipen prescriptions in these circumstances.
Category 3 patients with allergic rhinitis will benefit from patient education around minimisation of triggers and an optimised trial of standard pharmacotherapy (daily nasal saline rinse, daily intranasal corticosteroid spray, daily antihistamine). Category 3 patients with chronic urticaria (daily hives > 6 weeks) will benefit from education that their condition is not triggered by allergy. First line treatment is regular high dose (up to qid) non-sedating antihistamines, plus montelukast if required (unless contraindicated). If this is ineffective, please refer the patient.
Please refer to the ASCIA website for other health professional and patient resources, or or review the suite of ‘Immunology and Allergy‘ HealthPathways. Do not hesitate to contact the Immunology team to discuss clinical queries.
November 2020
SCGH Lipid Disorders Clinic
The Lipid Disorders Clinic at Sir Charles Gairdiner Hospital is now accepting referrals for patients within the North Metropolitan Health Service catchment.
Specialist expertise and genetic testing is provided for patients with problems such as familial hypercholesterolaemia, complex lipid disorders, statin myotoxicity and drug intolerance.
Urgent referrals are offered for:
- Homozygous familial hypercholesterolaemia
- Severe hypertriglyceridaemia
- Drug intolerance in patients with symptomatic atherosclerotic cardiovascular disease (ASCVD) and elevated lipids
- FH in pregnancy
- Severe statin myotoxicity
Consultation is also available for individuals with:
- LDL >5 and family history of premature CVS disease
- Elevated TG >5 (not explained by T2DM, alcohol or obesity)
- Elevated Dutch Lipid Clinic Network Score (DLCN) score >6
- Symptomatic ASCVD – lipid levels not at target
Prior to referral, please exclude secondary causes of dyslipidaemia, address significant lifestyle factors, calculate a DLCN score and consider imaging where appropriate. All referrals should be sent via the Central Referral Service.
If you have any queries or wish to discuss an urgent referral please email Dr Stjepana Maticevic at stjepana.maticevic@health.wa.gov.au or phone the Department of General Medicine on 6457 3172, fax 6457 3204.
See also the “Familial Hypercholesterolaemia” HealthPathway.
Dr Christine Pascott
Hospital Liaison GP, Sir Charles Gairdner Hospital
christine.pascott@health.wa.gov.au
0401 675 400
October 2020
New SCGH Frailty Rapid Access Clinic
A new geriatrician clinic is starting at Sir Charles Gairdner Hospital (SCGH) and accepting referrals from Monday 19 October 2020.
The Frailty Rapid Access Clinic (FRAC) is an innovative new outpatient clinic being offered by the SCGH Department of Rehabilitation and Aged Care. This clinic is for patients who would benefit from rapid geriatrician outpatient review, to avoid hospital admission. The clinic accepts referrals via Central Referrals Service (CRS), for patients over 65 years residing in the SCGH catchment.
FRAC aims to address the frustrating problem of hospital clinic wait times which can be weeks to months, leaving an area of unmet need. FRAC will provide an outpatient appointment with a geriatrician within seven days of receiving a referral, aiming to deliver fast, outpatient medical and multidisciplinary care to higher acuity older patients with Geriatric Syndromes.
Patients referred to the clinic will benefit from comprehensive geriatric assessment and Multidisciplinary care personalised to their needs. The clinic will work alongside the department’s usual Falls Clinic, Memory Clinic and Continence Clinic services.
Please direct referrals to the FRAC Geriatrician Clinic, SCGH Department of Rehabiliation and Aged Care, via CRS. Queries about FRAC can be directed to Dr Sarah Bernard, Geriatrician, Department of Rehabilitation and Aged Care, SCGH 6457 2594.
Dr Christine Pascott
Hospital Liaison GP, Sir Charles Gairdner Hospital
christine.pascott@health.wa.gov.au
0401 675 400
March 2020
SCGH Outpatient Referrals
Sir Charles Gairdner Hospital’s extensive review of outpatient services includes centralising the receipt of urgent referrals from GPs.
After patients have been discussed and accepted by a speciality clinician for urgent care within seven days, referrals should now be emailed to SPoRT@health.wa.gov.au unless otherwise directed.
Referrals for a specialist outpatient appointment not requiring care within seven days should continue to be sent to the Central Referral Service (CRS).
You can escalate the urgency of a referral previously submitted by resubmitting through CRS and highlighting your concerns. CRS can then prioritise and escalate the referral.
If the patient needs immediate care (within seven days) contact the speciality clinician via switchboard for direction.
Dr Christine Pascott
Hospital Liaison GP, Sir Charles Gairdner Hospital
christine.pascott@health.wa.gov.au
0401 675 400
March 2020
SCGH Outpatient Referrals
Sir Charles Gairdner Hospital is conducting an extensive review of outpatient services and processes to improve patient access to care, and this requires it to streamline it’s processes.
Referrals for a specialist outpatient appointment should be sent to the Central Referral Service (CRS) so that that patients can receive care in the most suitable location. This includes directing referrals to sites that offer state-wide services. Non-immediate referrals sent directly to the hospital cannot be actioned, and will be returned to the referrer.
Immediate referrals, i.e. where the patient needs to be seen by the specialist within seven days, must be discussed with, and accepted by, the relevant specialty. To discuss a patient who may require immediate review, phone the hospital switchboard on 6457 3333 and ask to speak with the relevant on-call consultant/registrar. If accepted, mark the referral as ‘immediate’ and fax to the hospital as directed by the consultant/registrar to the specific fax number provided.
For more information on how to refer for outpatient appointments, see the Central Referral Service guide for referrals.
Dr Lucy Gilkes
Hospital Liaison GP
Sir Charles Gairdner Hospital
Lucy.Gilkes@health.wa.gov.au
March 2019
New policy for better opioid prescribing on discharge from SCGH
In recognition of the high prevalence and difficulties of managing patients who misuse opioids in the community, an expert working group from the Acute Pain Service, pharmacy and other clinicians at Sir Charles Gairdiner Hospital have made some important changes to the practice of prescribing opioids on discharge from hospital. Discharge opioid medication will now be more closely scrutinised in light of the policy’s three target areas:
- Acute pain should resolve quickly and therefore opioids prescriptions should be short
- If patients do not need opioids in the 24 hours prior to discharge, they shouldn’t need them on discharge
- A weaning plan should be provided with discharge opioid medication to both the patient and the GP.
Hospital liaison GP, Dr Lucy Gilkes can be contacted with questions or concerns at lucy.gilkes@health.wa.gov.au GPs may also wish to review the “Prescribing Schedule 8 Medicines” HealthPathway.
Dr Lucy Gilkes
Hospital Liaison GP
Sir Charles Gairdner Hospital
Lucy.Gilkes@health.wa.gov.au
July 2019
New tool supporting patient centred care for at home dementia patients
Are any of your patients living at home with dementia, supported by family or friends? When these patients require hospitalisation and find it difficult to explain their needs and preferences, this new communication tool may be helpful.
The Focus on the Person form has been developed to gather important information for the hospital staff from people with dementia and/or their support partners. Completion of the form has been trialled and hospital staff members helped to design its format. Cognitive impairment project officers working in Sir Charles Gairdner Hospital, Fiona Stanley, Hospital, Royal Perth Hospital and the WA Country Health Service have promoted an awareness of how the information provided using this form can provide appropriately tailored care.
At Sir Charles Gairdner Hospital, work funded by the WA Health Nursing and Midwifery Office is now ensuring an agreed process at the hospital for accessing and using completed Focus on the Person forms.
Patients and their families can access the form and further information on the Alzheimer’s WA website.
Dr Lucy Gilkes
Hospital Liaison GP, Sir Charles Gairdner Hospital
March 2019
What do you think about the quality of our discharge summaries?
Sir Charles Gairdner Hospital (SCGH) is working to improve its discharge summaries. SCGH would like to know what GPs think about the quality and timeliness of current summaries. This will help the hospital to plan how they can be improved. Please take a few minutes to complete this very brief, confidential survey via the following link. The survey closes 31 March.
Dr Lucy Gilkes
Hospital Liaison GP, Sir Charles Gairdner Hospital
What do you think about the quality of our discharge summaries?
Sir Charles Gairdner Hospital (SCGH) is working to improve its discharge summaries. SCGH would like to know what GPs think about the quality and timeliness of current summaries. This will help the hospital to plan how they can be improved. Please take a few minutes to complete this very brief, confidential survey via the following link. The survey closes 31 March.
Dr Lucy Gilkes
Hospital Liaison GP, Sir Charles Gairdner Hospital