REFERRAL FORM 
Not Eligible: Residential Care or NDIS. People receiving Commonwealth Care Managed Care packages will be considered.
NAME: <PtName>
AUID/MRN:			
DOB: <PtDoB>
ADDRESS: 
<PtAddress>
PHONE: <PtPhoneH>	Mobile: <PtPhoneMob>	
GP NAME: <DrName>			
PRACTICE NAME:  	<Practice>		
<Practice:Street>		
Phone:<Practice:Phone>	  Fax: <Practice:Fax>
Indigenous status: <PtEthnicity>	
Has verbal consent for this referral and information sharing been obtained from this person?      	<Verbal consent for referral/ info sharing been obtain>	
REFERRAL SUBMITTED BY: (please print) 
Name:	<Referee Name>	      Title: <Referee Title?>
Referee Organisation: <Referee Organisation>
Referee Phone number: <Referee Phone Number> DATE OF REFERRAL: <Date>	
This program is eligible to all people living in Western NSW LHD who are over the age of 16 and have the following Chronic Conditions: PLEASE TICK IN THEc

Diseases: <Pt. >16yrs is eligible if have 1 or more condition?>	
Diabetes	<Does Pt. have Diabetes?>	Respiratory Disease	<Does Pt. have Respiratory Disease?>	
Cardio Vascular Disease	<Does Pt have CVD?>	Renal Disease	<Does Pt. have Renal Disease?>	
Is this person:
<At risk of Hosp. admission due to their Chronic Dx>  At risk of hospital admission due to their chronic disease?
<Display lack of understanding their Chronic Disease>  Displaying a lack of understanding for their chronic disease?
<Needs more intensive Care Co ord. then is current>  Requiring more intensive care coordination than is currently able to be provided by General Practice?
<Having trouble accessing & using right services?>  Having trouble accessing and using the right services for their care?
<Having difficulty managing mutliple services & appt> Having difficulty managing multiple services and appointments?
Other:
<Other - Please make any relevant comments re: Pt. >	
What are the client's goals?
<What are the patient's goals?>	
What goals is the patient wanting to achieve?
<What goals is the patient wanting to achieve?>	
Does person have a current:
Health Assessment 				<Does Pt. have a current Health Assessment?>
Shared Care Plan/GP Management Plan	            <Does Pt. have a current Share Care Plan/GPMP?>
Team Care Arrangement with their GP	            <Does Pt. have a current TCA with their GP?>
Medication Review				<Does the Pt. have a current Medication Review?>
<Please attach the above if available & any other. >
Please attach any accompanying documents which may enhance this referral	
Does the patient have a current:
Advanced Care Directive 				<Does Pt. have a Advanced Care Directive?>
My Health Record (MHR)				<Does Pt have a My Health Record (MyHR)>
If no to MyHR would the patient like to be registered	<If no to MyHR would Pt. like to be registered?>   	
Current services being received by person? 
<List current services being received by person?>
	
Does this person have a Carer/Guardian?		<Does this Pt. have a Carer/Guardian?>
If Yes Carers/Guardian’s Name:                                        <If Yes Carers/Guardian's Name>
Does this person care for someone else?    		<Does this person care for someone else?>
Details: 
<Please provide details if they care for someone else>	

What can Care Coordinators do?

•	Link the patient and family with appropriate community based services providing support for daily living and social needs;
•	Conduct a comprehensive Holistic Person Centered assessment and provide to the GP;
•	Participate in multi-disciplinary case conferences with the GP, client and relevant others;
•	Assist in arranging the health services identified in a GP Management or Team Care Plan;
•	Assist the patient to participate in regular reviews from their primary care providers;
•	Support the patient’s adherence to treatment regimens (eg. medication compliance);
•	Help the patient better understand their disease through Health Coaching;
•	Support and encourage the patient and their family to develop self-management skills for their chronic condition.

	

Argus Summary:
Patient Name: <PtSurname>, <PtFirstName>  DOB: <PtDoB>
Recipient: <AdrName> Date of Report: <Date>