REFERRAL FORM
GCPHN Frailty Program

Phone Joyce McSwan for further information on 0412 327 795
Forward completed Referral via Medical Objects (preferred) to:
	Name: Joyce McSwan
	Provider Number: JM4226000Q0
or Fax 07 3539 9801
DATE:  Miscellaneous.Date
 PATIENT DETAILS 
RE: Patient Demographics.Full Name	DOB:  Patient Demographics.DOB	Gender:  Patient Demographics.Gender	
Address: Patient Demographics.Address

Home Phone:  Patient Demographics.Phone (Home)	Work Phone: Patient Demographics.Phone (Work)	Mobile Phone: Patient Demographics.Phone (Mobile)	

Patient presentation

Patient presentation

PAST HISTORY
Has the patient previously attended a falls prevention or frailty program/clinic?   Frailty program
If yes, please specify where and when: If yes, specify

Clinical History:  Clinical Details.Problem List (Current) With Comments, Onset Year
Clinical Details.Problem List (Resolved) With Comments, Onset Year
Investigations:  Clinical Details.Result List (Selected)

Medications:  Clinical Details.Medications - Current Regular

Allergies:  Clinical Details.Allergies

Smoking:  Clinical Details.Smoking

Alcohol:  Clinical Details.Alcohol

Patient must meet ALL the following criteria to be eligible for the program:

•	The patient is >65 years old (Older Persons) or >55 years old (Aboriginal & Torres Strait Islander)
•	The patient has scored >1 in the FRAIL scale risk assessment (please see the FRAIL scale risk assessment on the last page of this referral)
•	The patient is not a palliative care patient
•	The patient does not currently reside in a Residential Aged Care Home
•	The patient requires improved self-management strategies and skills to optimise ongoing care
•	The patient is able to give voluntary, informed consent for the ongoing collection of audit data.

Eligibility criteria	REFERRING GP/ORGANISATION DETAILS 
GP's Name:  Treating Doctor.Name
Practice.Name
Practice.Address
Phone: Practice.Phone
Fax: Practice.Fax
Email: Treating Doctor.E-mail
Provider Number: Treating Doctor.Provider Number

REFERRING ALLIED HEALTH PROFESSIONAL DETAILS (if this applies) **A GP Sign off is mandatory for this referral to be accepted**
AHP's Name:  
Allied Health Profession:  
Organisation:  
Phone:  
Fax:  
Email:  	

On the receipt of this referral, the patient will be contacted with details of the Gold Coast Primary Health Network's Frailty Care in Community, Healthy Ageing Program to be reviewed with an initial service assessment. Our Service Assessments will be held at our office at Corporate House, Varsity Lakes. The group-based Frailty Care in the Community Program will be held at various north and south community centres on the Gold Coast. Patients will be allocated accordingly to suit their individual needs. Please provide for your patient the  "Patient Information Sheet" for their further information. Patients can also call us directly to enquire further on: 0412 327 795

The Frailty Care in the Community, Healthy Ageing Program is supported by funding from Gold Coast Primary Health Network through the Australian Government's PHN Program. GCPHN is collecting your personal information for the purpose of assisting its activities and functions in the primary health care sector. Your contact details may be used to forward information and notifications from GCPHN. In some circumstances we may provide your information to our funding agency (Dept of Health and Aged Care) or to service providers that enter into legal contracts with us which are bound by confidentiality.  There is no legal requirement for you to provide your personal information, however if you chose not to disclose your personal information this may exclude you from our services and programs. We do not routinely disclose information overseas. For further information on how we manage your personal information see our website https://gcphn.org.au/privacy-policy

FRAIL SCALE RISK ASSESSMENT
	Questions	Scoring	Results	
Fatigue	How much of the time during the past 4 weeks did the patient feel tired?
A = All or most of the time
B = Some, a little or none of the time	A = 1
B = 0		
Resistance	In the last 4 weeks, on their own and not using aids, has the patient had difficulty walking up 10 steps without resting?	Yes = 1
No = 0		
Ambulation	In the last 4 weeks, on their own and not using aids, has the patient had difficulty walking 300 metres OR one block?	Yes = 1
No = 0		
Illness	Does the patient have the following conditions?
•	Hypertension
•	Diabetes
•	Cancer (not a minor skin cancer)
•	Chronic lung disease
•	Heart attack
•	Angina
•	Asthma
•	Arthritis
•	Kidney disease	0-4 answers = 0
5-11 answers = 1		
Loss of weight	Has your patient lost more than 5kg or 5% of body weight in the past year?	Yes = 1
No = 0		
	TOTAL SCORE			
	Scoring: Robust = 0     Pre-frail = 1-2    Frail = >3			

You can also use the online Frail Scale Risk Assessment calculator: https://painwise.com.au/frail-scale/