RAPHS - Extended Care Support Team

Community Health Service

Description

Service delivery during COVID-19
Alert Level	Service Delivery
Level 4	Accepting referrals. No home visits. Virtual or phone consults/assessments only.
Level 3	Accepting referrals. No home visits. Virtual or phone consults/assessments only.
Level 2	Accepting referrals. No home visits. Virtual or phone consults/assessments only.
Level 1	TBC

The RAPHS Extended Care Support Team was established to provide support, advice and guidance to RAPHS practices and community organisations.

The team combines the resources of nursing, pharmacy, hospital and community-based health and social services through an integrated multidisciplinary team.

The service aims to:

Reduce unnecessary ED/hospital admission/readmission for at risk patients.
Support transitional care for complex patients discharged from the hospital setting to home.
Support complex patients to better self-manage their personal health in their own environments.

How do I access this service?

Referral

For practitioners:

If you have patients who you consider would benefit from the RAPHS team input, please refer using the ‘Extended Care Support Team’ referral form available on your PMS…

Clinical Assessment and Care Coordination

In collaboration with the GP practice, the team will assist with clinical assessment and care coordination of complex patients in their home, outreach visits or at RAPHS. This may include:…

Patient Access to Community Service Providers

In collaboration with the GP practice, the team will assist in improving patient access to community service providers, e.g. community dietitians, heart failure nurses, WINZ, etc.

Addictions

Alcohol
Drug

In collaboration with the GP practice, the team will assist with support for patients presenting with moderate to severe addiction problems who do not meet the secondary service criteria or…

Mental Health

In collaboration with the GP practice, the team will assist with support for patients presenting with moderate to severe mental health problems who do not meet the secondary service criteria…