GPLink Update from the GPs at Royal North Shore
Issue 6 March 2024
In this edition we provide information about the keeping well and independent program, a collaboration with the Sydney North Health Network. We also focus on two relatively new services, the hyperemesis gravidarum clinic and a clinic specifically for people with cardiovascular disease without traditional risk factors. Finally, for your patients with children starting school we provide information about NSLHDs transition to school videos.
Keeping Well and Independent Program The RNSH GP Liaison Officers (GPLOs) are working with the Sydney North Health Network to support the Keeping Well and Independent Program which assists practices to help complex, older patients avoid hospitalisation. This program provides
This program is available to all practices within the SNHN area. The PHN will provide support including hospitalisation data, orientation, patient selection and quarterly reviews. The program is available to patients who are: • 75 years or older • Living at home in the community-not an RACF • Living within the Sydney North PHN-because services involved only cover the SNPHN area. • Considered to be at high risk of preventable hospitalisation There is a detailed online guide to the program at this link: The Keeping Well and Independent Program -Sydney North Health Network. For further information about the program please contact Sue Coxon at the PHN or the GPLOs. Sue Coxon Project and engagement Officer 9432 8298 scoxon@snhn.org.au Dr David Cosgriff & Dr Luke Morphett GPLOs nslhd-gplo@health.nsw.gov.au
resources for you to self-report CPD to the RACGP. For participating practices, payments are provided for the following: • A practice sign-on payment • A payment for each patient enrolled in the program • An outcome incentive payment, for patients who remain stable or improve over 12 months, measured by their score on the EQ-5D-5L (patient outcome measure) or frailty screening questionnaire • Extra time via an optional Care Coordination grant (about 16 hours, per enrolled patient, per year) for your staff to undertake planned activities including selecting patients based on primary care and acute data, risk stratification, recalls, health assessments, MDT meetings and similar tasks.
Hyperemesis Gravidarum Hyperemesis Gravidarum usually has an onset between the 4th and 10th week of pregnancy. For the majority of women symptoms are self-limiting, however approximately 10% of women will continue to have symptoms until birth. Our district now has a specific service to help these women. The Sydney North Healthpathway has been updated to reflect the NSW Health Guideline and includes information about evidence based medication regimes. Pregnant women who have a PUQE-24 score >7 and live within NSLHD can be referred to the Northern Sydney Virtual Care service (NSVCS) to support medication optimisation and if required arrange for the woman to receive IV fluids in their home. Please see the PUQE below. It is our goal that with the Healthpathway and referral to the NSVCS that women have improved symptom management and access to care, as well as reduce ED presentations and hospital admissions.
PUQE Score
Please see Nausea and Vomiting in Pregnancy and Hyperemesis Gravidarum HealthPathway for more information. Username: healthpathways Password: gateway Referral information Please call the Virtual Care service on 0400 303 716 (9am–5pm, 7 days)
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Coronary artery disease without traditional risk factors (SMuRFless CAD) Clinic Do you have a patient with coronary artery disease but not these risk factors? Consider referring to our specialty clinic The SMuRFless CAD Clinic was established by a global team of experts to find out why some people develop coronary artery disease (CAD) without having standard modifiable cardiovascular risk factors (SMuRFs) and why these people have poorer health outcomes in comparison to people with CAD who do have one or more SMuRFs. Why refer? A cardiologist with a special interest in CAD without traditional risk factors will review your patients’ medical history and work with you to understand if they have less common risk factors for CAD. Our team will optimise their care management. This does not replace your care or that of their usual cardiologist (if relevant). How can I refer? You can refer patients to the SMuRFless CAD service via HealthLink eReferrals that are embedded in your practice software. Location • Level 4, Diagnostic Cardiology Royal North Shore Hospital St Leonards, NSW, 2065 OR • telehealth Criteria • Your Patient must have been diagnosed with CAD or have a family history of CAD AND • Not have high blood pressure, high cholesterol or diabetes AND • They must not have smoked in the past 12 months
More Information Michael Gray Clinical Research & Strategic Partnerships Manager Michael.gray2@health.nsw.gov.au 0491 732 195
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Supporting kids to have a healthy start to school
If you have patients with a child starting school for the first time this year or next, refer them to Northern Sydney Local Health District’s ‘Supporting the Transition to School’ video series. The videos present practical ideas from allied health professionals and teachers to support kids have a healthy and positive start to school. “The transition from home or childcare to school is a very important period in a child’s development,” explained population health promotion’s Kara McDonnell. “By ensuring they have well developed physical, emotional and social skills, like those presented in the videos, kids can flourish in the new learning environment.”
The videos cover the following topics: • Fine & gross motor skills • Fundamental movement skills • Developmental milestones
• Developing independence and self-care skills • Interpersonal and self-management skills These skills can help kids with important school tasks such as writing, sitting at desks, drawing, using scissors, dressing, eating, and going to the toilet independently and more. The videos are divided into two streams, one for teachers and educators, the other for parents and carers. However, all health professionals caring for the health of children aged 4–6 years are encouraged to share these videos with clients and community groups. Visit https://nshp.com.au/TransitionToSchool for more information and watch the videos.
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Feedback
We aim to improve communication between the hospital and primary care; improve patient experience of outpatients and ensure patients arrive back at their GP with adequate information to plan their ongoing care. We welcome your feedback on this information about the clinics at Royal North Shore. Please let us know if the format or content can be adjusted to better communicate the services available at the hospital. Email: NSLHD-GPLO@health.nsw.gov.au
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