Referral date:   	<<Miscellaneous:Date>>	
PROVIDER DETAILS	
GP Name	<<Doctor:Name>>	
Provider Number	<<Doctor:Provider Number>>	
Practice Name	<<Practice/Location:Name>>	
Practice Phone	<<Practice/Location:Phone>>	
Practice Fax	<<Practice/Location:Fax>>	
Alternate GP	<<If you are not the patient's main GP please name:>>	
PATIENT DETAILS	
Name	<<Patient Demographics:Full Name>>	
Dated of Birth	<<Patient Demographics:DOB>> (<<Patient Demographics:Age>>)	
Medicare Card	<<Patient Demographics:Medicare Number>> | <<Patient Demographics:Medicare Expiry Date>>	
Health Care Card	<<Patient Demographics:Health Insurance>>	
Address	<<Patient Demographics:Full Address>>	
Phone	H: <<Patient Demographics:Phone (Home)>>M: <<Patient Demographics:Phone (Mobile)>>	
Sex | Identifies as Transgender	 <<Patient Demographics:Gender>> | <<Patient Demographics:Transgender>>	
Ethnicity	<<Patient Demographics:Ethnicity>>	
Preferred Language	<<Patient Demographics:Language Preferred>>	
Interpreter required:	<<Patient Demographics:Requires Interpreter>>	
FAMILY AND SOCIAL HISTORY	
Does the patient work?	<<Patient Demographics:Occupation>>	
Does the patient have a partner?	<<Patient Demographics:Marital Status>>	
If yes, partners full name:	<<Patient Partners name: >>	
Does the patient have a carer?	<<Does the patient have a carer?>>	
If yes, carers full name:	<<If yes, what is the carers name?>>	
If yes, is the carer related?	<<If yes, what is the carers relationship to the patient?>>	
Partner/Carers contact phone number/s:	<<If yes, Partner/Carers contact phone number:>>	
Patient consents to referral:	<<Patient consents to referral?>>	
Consent to contact partner / carer?	<<Consent provided to contact partner / carer?>>	
REFERRAL DETAILS	
Reason for referral:	<<Reason for Referral: >>	
The patient is considered to have limited access to multidisciplinary care from allied and other health professionals due to: (Please tick all that apply)
	<<Related issues: Select all that apply:>>	
Current Chronic Disease Management	<<Select all that apply: Include selected documents >>

Note: Please attach a copy of the relevant care plan/s to this form.	
Supporting Comments:
	<<Supporting \ Other Comments?>>	
MEDICAL HISTORY	
History:
<<Clinical Details:History List>>	
Medications
<<Clinical Details:Medication List>>	
Allergies:
<<Clinical Details:Allergies/Adverse Reactions>>	
Immunisations:
<<Clinical Details:Immunisation List>>	
PATIENT COHORT	
	
ELIGIBILITY CRITERIA	
Eligible patients:
•	Reside in the specified Local Government Areas (LGAs) – City of Frankston and the City of Greater Dandenong
•	People over the age of 18 years with/without a chronic disease and identified as at risk of hospital admission and presentation to Emergency Department (ED), particularly in the After-Hours period by Community Pharmacies and/or General Practices (GPs) for reasons that may include any of the following: 
o	If known - Disengaged from primary health and have been recently discharged from hospital or ED (Frequent attendees) and not involved in any other program, at risk of reattendance at ED in the After Hours or admission to hospital 
o	Have two or more chronic conditions
o	Have one or more chronic conditions and are from one of the following priority groups: 
-	Aboriginal or Torres Strait Islander
-	At risk of homelessness
-	Culturally and Linguistically Diverse (CALD)
-	Refugee
-	Have a Mental Health condition
o	If known - who attend EDs frequently or risk of attending EDs often
o	If information known -has had a minimum of 2 potentially avoidable hospital admissions in one current year
o	Not attending clinical and non-clinical appointments
•	Displays tendency to medicalise their social issues (examples; increased dependance on medical care or the increased use of prescription medication and/or substance dependance).	
Excluded patients​:
•	Current recipient of HARP (Hospital Admission Risk Program). 
•	People receiving post discharge services from any Local Hospital Network that would replicate contracted program services. 
•	DVA (Department of Veterans Affairs) Gold and White card holders. 
•	Reside in a residential aged care facility. 
•	Current recipient of palliative care services. 
•	Recipient of NDIS (National Disability Insurance Scheme). 
•	On Workcover / Transport Accident Commission  
•	People not residing in the targeted LGAs of the City of Frankston and City of Greater Dandenong. 
•	People already receiving similar services from the Respondent (provider)	
TIPS TO COMPLETE THIS REFERRAL FORM	
•	Ensure the patient is aware of referral being made to Care Coordination Support Service
•	Ensure that the patient has access to a telephone and include all phone numbers in patient details section
•	Ensure that all the relevant limited access to multidisciplinary care due are ticked in referral details section 
•	Please include any relevant details in the Additional information section or as an attachment 
•	Please advise in the Additional information section if the patient is involved with:
•	Pharmacy support 
•	Specialist care service
•	Palliative Care
•	Oncology	
FURTHER INFORMATION	
For referral enquiries, please phone: 1300 300 122 or email: SCReferrals@silverchain.org.au
For general enquiries, please phone: 1300 650 803 and ask for Care Coordination Support Service (South Eastern Melbourne)
Silverchain: https://www.silverchain.org.au/
South Eastern Melbourne Primary Health Network: https://www.semphn.org.au/	
RELEVANT INVESTIGATIONS	
<<Summary:Investigation Results (Selected)>>