Who we care for

We form a GP-led team around patients with chronic illness who:

  • are at a high risk of significant health decline; and
  • have support from other relevant health care services that service the Canowindra area

What we offer

  • symptom managemnt plans involving all members of the team to deal with exacerbations of chronic conditions outside of clinic times
  • the GP in a GP-led team
  • coordination of the team, using MBS-compliant care plans, team-care arrangements, and case-conferences
  • a protocol for health practitioners to raise queries and concerns directly with the team GP
  • occasional clinics for patients in Canowindra

How to refer

To nominate a GP-led team for a chronic patient, please complete the form below. Please note that your referral is not to our GP, but to the pratice.

Referral Form

Does the patient ... (CHOOSE ALL THAT APPLY)

Has the patient ...

SCORING Risk Score: 0/6
To benefit from having a team, we find that patients need to score between 4 - 6. A person who scores < 3 is usually not sufficiently invested. We may sometimes admit a 3.

Practitioner Details

Choose a secure communication method

Enter the number we would see when you call us, so we can easily tell it is you calling. We will not call or SMS this number except to return your call ... we will always initiate fresh contact via your practice number.

Patient Details

We currently only accept referrals for people who live in places where we can field a team.
Mobile phone preferred
We will contact the patient on the above number if this referal if accepted.

Application

What we don't offer

  • a 'team of 1 GP'
  • a full-time general-purpose GP clinic
  • same-day or next-day appointments, even for urgent matters
  • direct patient access to the GP via phone