CALHN Integrated Care

Integrated Care (IC) is a clinical service stream of the Central Adelaide Local Health Network (CALHN).

CALHN Integrated Care (IC) provides contemporary, innovative clinical care at the important interface between hospitals and community. IC focuses on:

  • Optimising delivery of quality hospital-level care in the community,
  • Preventing unnecessary hospital presentations and admissions and
  • Facilitating safe and connected transfer of care between hospitals and primary care.
  • Right care, right time, right place.

IC plays an important role for consumers whose care needs are unable to be safely managed by primary care but do not require emergency-level care or ‘bricks and mortar’ hospital admissions. IC is well positioned to support vulnerable consumers who may have complex physical and psychosocial needs.

A key strength of the IC model is development of consumer-centred care pathways optimise partnerships with consumers, CALHN Programs, other Local Health Networks, Non-Government organisations, General Practices and other community and primary care stakeholders.

IC services are delivered from CALHN hospitals and community health hub locations.

 

BRIGHT

‘Bringing Responsive, Integrated Healthcare To our community’,

BRIGHT provides multidisciplinary rapid assessment and urgent care for patients who:

  • have care needs that are unable to be met by primary care or community services and
  • are on trajectory to present to a hospital emergency department, but do not require ‘emergency level’ care and
  • can safely receive care in a community health care setting.

The service supports an important ‘gap’ in health care service delivery and does not duplicate other urgent care type models that are available.

The BRIGHT multidisciplinary team is made up of nurses, nurse practitioners, doctors, physiotherapists, pharmacists, social workers, podiatrists, occupational therapists and dietitians.

BRIGHT is a referral-only service and operates from multiple sites (Sefton Park and Woodville). Referrals may be received from SA Ambulance Service, SA Virtual Care Service, General Practitioners, community health care providers, Non-Government organisations or consumers may be redirected from our Emergency Departments.

BRIGHT offers

  • Timely assessment and treatment for consumers with complex unmet health needs who are likely to (re) present to an emergency department or hospital.
  • Short-term intervention, wrap-around support and onward referral to community care so the consumer’s ongoing care needs can be met.
  • Access to CALHN hospital specialty services, when required, including direct admission pathways.
  • Expertise to support vulnerable consumers who may have complex physical and psychosocial needs.
  • Speciality face-to-face and telehealth consultation
  • Medical imaging
  • Telemetry
  • Pathology
  • Supported transport

How to refer to BRIGHT Woodville and BRIGHT Sefton Park

  • BRIGHT services are open 365 days a year 0830-2130
  • Is a referral only service, patient walk in’s are not supported at this time
  • Referrals can be made by contacting a dedicated clinical referral hotline – 7133 9992 This number is for referrers only
  • A Navigator will advise the most appropriate BRIGHT service location based on capacity at each site and patient need
  • Patients requiring emergency-level medical care should continue to be treated through SA Ambulance Service and/or an emergency department

For more information please contact:
Referral Hotline: (08) 7133 9992
Fax: (08) 8342 0053
Email:  HealthCALHNIntegratedCare@sa.gov.au

 

CALHN Integrated Care Coordinators (CICC)

Provide expert clinical advice to external referrers and CALHN clinicians in hospital avoidance strategies and alternate treatment options for patients. Guide clinicians through appropriate referral processes. The main focus of CICC is to prevent unnecessary emergency department presentations and facilitate safe and timely discharges to appropriate community services, reducing the overall length of stay in hospital.

For referrals and/or health professional and patient enquiries please contact us via the CICC Coordinator: 7133 9998

Email: HealthCALHNIntegratedCare@sa.gov.au

 

Iron Infusion Clinic

Iron Infusion Clinic is available to CALHN patients who meet the requirements for Ferric Carboxymaltose infusion, do not have any risk factors requiring inpatient admission and would otherwise be referred to CALHN acute sector.

Service Location: Shop 5/221 Main North Rd Sefton Park 5083

Referral process for GPs: For URGENT referrals when iron infusion to be completed within 1-2 weeks please call CICC Coordinator 7133 9998 or BRIGHT Referral Hotline 7133 9992.  All other iron infusions will be completed within 4 - 6 weeks.                                                                        

Patient information can be found via  https://bloodsafelearning.org.au/iv-iron-tools/ or contact:

Ph: (08) 7133 9998
Fax: (08) 8342 0053
Email: HealthCALHNIntegratedCare@sa.gov.au

 

Refugee Health Service

The State-wide Refugee Health Service (RHS) located in CALHN, provides early intervention specialist health services for Humanitarian Refugees and Asylum Seekers, with supported transition to mainstream primary care services.

Supporting Australia’s humanitarian efforts during times of international unrest, RHS leads SA’s urgent health care response for new arrivals fleeing global crisis. This includes pro bono services for non-Medicare asylum seekers, such as families and individuals from Afghanistan, Gaza, and Ukraine.

For referral details or more information please contact:

Telephone: (08) 7133 9996
Fax: (08) 8237 3949
Email: health.adminmhs@sa.gov.au
Website:  Refugee Health Service web page    

 

O’Brien Street Practice

O’Brien Street Practice (OBP) located in the Central Business District (CBD), provides a service for patients with HIV, and primary health care consults with a focus on ensuring equity of access to health care is fair to all health consumers. This includes specialised HIV, Post exposure prophylaxis (PEP) and Pre-exposure prophylaxis (PrEP), Hep B and C, and sexual health services.

For referral details or more information for health professionals please telephone:

Telephone: (08) 7133 9997
Website: O'Brien Street Practice 

 

GP Integration Unit (GPIU)

GPIU was established in collaboration with the Adelaide Primary Health Network to improve patient care by facilitating and strengthening collaboration, communication and integration between general practices and the Central Adelaide LHN.

The GPIU actively supports the streamlining of clinical information systems and advocates for ongoing integration between primary health and out-of-hospital services.

A point of contact for GP’s for support with non-urgent CALHN service and clinical advice to enable coordinated care between tertiary and primary settings. Interface between CALHN and referring GP’s to build capacity within primary care via consultation and education to CALHN and GPs.

Contact the General Practice Integration Unit

Our GPL Nurse is available Monday to Friday, between 8am and 4pm.

Telephone: (08) 7133 9995
Fax: (08) 7074 6147
Email: health.calhngpintegrationunit@sa.gov.au
For more information see the GP Liaison web page.

 

CALHN IC Geriatric Services

All CALHN IC Geriatric Services referral criteria,

  • People over the age of 65 (50 if Aboriginal) and the older
  • Person must reside in the CALHN catchment.

Services will be provided face to face or virtually.

All services receive medical support by RAH Department of Geriatric and Rehabilitation Medicine.

IC Geriatric Services Single Point of Contact (SPOC)

Single Point of Contact’ for CALHN and the community (including SAAS/VCS/GP/NGO’s) has been now implemented due to a recognised need and provides; a single entry into CALHN Geriatric services including GITH, MCGS, and RACF in reach providing expert system navigation and redirection to alternate care pathways as appropriate.

Geriatrics in the Home (GITH

GITH is a 6 – 10-day hospital avoidance or substitution program with a restorative resilience building focus. GITH operates as a comprehensive inpatient service based in the community. It is staffed by clinicians who specialise in Geriatric care and provide a holistic multidisciplinary approach. Patients admitted to GITH will be classified as an in-patient of the Royal Adelaide Hospital. They can receive up to three home visits per day from members of our team in their home dependent on individual goals and clinical need. GITH patients will have access to 24-hour telephone support.

Multidisciplinary Community Geriatric Service (MCGS)

MCGS is an outpatient service which provides short-term case management to older people with complex needs across CALHN. Patients referred to the service generally have a combination of medical, environmental, and social complexity. The team works with the older person in collaboration with a range of health and service providers, families, and carers to optimise health outcomes and improve quality of life for older people living in the community and residential care facilities.

IC RACF in-reach

IC RACF in-reach is an outpatient service supporting RACF patients to receive support in place and avoid transfer to hospital when appropriate.
Assisting with transition from hospital to RACF with outreach support.  Utilising other out of hospital services as required. Providing the facility with confidence and support when accepting a new resident, particularly with Behavioural Psychological symptoms of Dementia (BPSD).

 

CALHN Hospital in the Home

CALHN Hospital in the Home (HITH) is a community inpatient service providing acute care to patients as a substitute for treatment in hospital, meaning people can return home sooner or, in some instances, avoid a hospital admission altogether. Care can be delivered at a patient’s usual or temporary residence, in a HITH clinic or via telehealth. The HITH team is made up of CALHN doctors, nurses and allied health professionals.

 

There are many benefits to being treated by the HITH team:

Same quality care in the comfort of your own home or at one of our clinics Eat your own food when it suits you, sleep in your own bed, and be surrounded by loved ones Less likely to get infections compared to a hospital

 

CALHN HITH offers different care options to other community inpatient services, and may be suitable for:

  • Patients who require ongoing input from CALHN specialist services
  • Patients who are awaiting a clear care plan and have a predicted longer length of stay
  • Patients requiring services or investigations that are unable to be accessed by other community-based inpatients services and would otherwise need to stay in a physical hospital.

CALHN HITH operates 365 days per year and provides 24-hour telephone support. The service is free for Medicare-eligible patients.

For further information about the CALHN HITH service, contact the HITH Liaison on T: (08) 7133 9994 or visit Hospital in the Home at the Royal Adelaide Hospital website.