Galangoor Duwalami Primary Healthcare Service  -  Institute for Urban Indigenous Health (IUHI)

Integrated Team Care (ITC) General Practitioner Referral Form Care Coordination and Supplementary Services

The ITC program provides assistance for Aboriginal and Torres Strait Islanders with chronic health problems who require help in coordinating their healthcare and/or require help in accessing services and medical aids not available through other funding sources, or not without lengthy delays.

Re-enrolment is required at the commencement of each calendar year for ongoing services.

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Patient eligibility

Patient has a current 715 ATSI Health Check?:     <Patient has current 715 ATSI Health Check?>
If yes, see Outreach Worker
Outreach Worker - if client identifies as Aboriginal and/or Torres Strait Islander, client is eligible for Outreach Worker Services
Patient identifies as: <Patient identifies as>
Support required: <Support required>

Patient has a current GP Management Plan and Team Care (721+723)?: <Curent GPMP and Team Care (721+723)?>

The patient has a significant chronic disease (select one or more as appropriate):
<Significant chronic disease/s>
If other, please specify: <If other, please specify>

Referral date: <TodaysDate>
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Referring GP details

Name: <DrName>
Phone number: <DrPhone>   Fax: <DrFax>
Practice name: <Practice>
Practice address: <UsrAddress>
Source of referral: <Source of referral>   

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Patient details

Surname: <PtSurname>   First name: <PtFirstName>
Date of birth: <PtDoB>
Gender: <Patient sex>
Residential address (including postcode): <PtAddress>
Home phone number: <PtPhoneH>   Mobile number: <PtPhoneMob>

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Care coordination*

Patient requires care coordination: <Patient requires care coordination>
Level of assistance: <Level of assistance>
Anticipated duration: <Anticipated duration>
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Supplementary services**

Patient requires funding assistance for: <Patient requires funding assistance for>
Other (specify): <Other (specify)>
Note - services NOT covered include medication costs, operations or hospital stays

Consider other funding sources, including
- MAAS (Medical Aids Subsidy Scheme) - e.g. continence aids
- NDSS (National Diabetes Subsidy Scheme) - e.g. insulin needles
- QAS (Queensland Ambulance Service) - e.g. clinic cars
- Aged care funding, including CAPS packages - e.g. Vital Call, Aged Care transport
- QUMAX Funding - e.g. DAA, glucometers, sphygmomanometers, spacers, certain medications, testing lancets
- Australian Disability Parking Permit
- Queensland Government Taxi Subsidy Scheme
- Centrelink Essential Medical Equipment payment - electricity subsidy for running medical equipment such as CPAP, home dialysis, nebuliser etc.

Referral authorised by GP (sign): __________________________________________

Date:_____________________________________________________________________

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Consent form

(Mark box x if consent is given)

¨ ITC CCSS PROGRAM CONSENT 
• My GP or Care Coordinator has discussed the CCSS Program Fact Sheet with me. I understand what I have been told, any questions I had about the Program have been satisfactorily answered, and I now want to participate.
• I understand that my participation is voluntary and that I have the right to withdraw from the Program at any time.
• I understand that a range of health and community service providers may collect, use, and disclose my relevant personal information as part of my care.
• I understand that the personal information collected by these organisations will be maintained consistent with National Privacy Principles. It will remain confidential except when it is a legal requirement to disclose information; or where failure to disclose information would place me or another person at risk; or when my written consent has been obtained to release the information to a third party.
• I understand that statistical information (that will not identify me) will be collected and used to see how well the Program is working and help improve services for Aboriginal and Torres Strait Islander people.

¨ CASE CONFERENCE CONSENT 
You, or one of the professionals involved in your care, can ask your care coordinator or GP to arrange a case conference at any time. Case conferences provide an opportunity for you and the people who provide medical and other services to meet and plan your future care.

The health care team including Care Coordinator will arrange a case conference upon enrolment of all new clients to ITC to discuss required services and care coordination.
You are encouraged to attend case conferences but can choose not to or you may send someone on your behalf. A record will be kept in your medical notes and discussed with you and (if appropriate and with your agreement) your carer.
• I consent to my medical team arranging a case conference regarding my health management

¨ HOME MEDICATION REVIEW (HMR) CONSENT 
- I consent to having a Home Medication Review (HMR).
- I regularly attend <Patient's pharmacy> in <Pharmacy location>.
- I consent to the release of my medical history and medication to the pharmacist.
- I understand the pharmacist will conduct the HMR and communicate to me information arising from the HMR.
- I consent to the release of my Medicare Number to the pharmacist for the pharmacist's payment purposes.

Patient signature and consent:__________________________________________________

Patient name: ________________________________________________________________

Date:________________________________________________________________________

I have discussed the proposed referral to the CCSS Program with the patient and am satisfied that the patient understands and is able to provide informed consent to this.

Referring GP's signature:_______________________________________________________

GP name: ____________________________________________________________________

Date of referral:_______________________________________________________________

Care Coordinator signature: ____________________________________________________

Name of Care Coordinator:_____________________________________________________

Date:_________________________________________________________________________

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Notes

*Care Coordination Criteria
Client
• is at significant risk of experiencing otherwise avoidable (lengthy and/or frequent) hospital admissions
• is at risk of inappropriate use of services, such as hospital emergency presentations
• is not using community based services appropriately or at all
• needs help to overcome barriers to access services
• is unable to manage a mix of multiple community-based services

**Supplementary Services Criteria
- to address risk factors, such as a waiting period for a service longer than is clinically appropriate
- to reduce the likelihood of a hospital admission
- to reduce the patient's length of stay in hospital
- as not available through other funding sources
- to ensure access to a clinical service that would not be accessible because of the cost of a local transport service.

Please fax completed form to (07) 4121 2356