Identifying Eligible Patients

There are various ways that you can identify eligible patients for this program:

Eligibility Criteria:

  • For patients living independently in the community.
  • For Patients that are 75 years and older.
  • For Patients that are living within the Northern Sydney Region.
  • For patients that are at risk of hospitalisation in the next few months. 

Also, your Practice has a set minimum and maximum target for enrolment into the Program. To know your minimum and maximum numbers for enrolment into the Program please refer to the Program’s Memorandum of Understanding MoU. 

  1. Use the LHD’s Risk of Hospitalisation (RoH) Score which is a quarterly list of patients (that will be sent to you) that have been to the public hospitals in Northern Sydney. A description of how to retrieve your patient list is below.
  2. Use Primary sense – instructions here.
  3. Use your clinical judgement to make an assessment of patients that you feel are at risk of hospitalisation or deterioration in the next 3-6 months.
  4. Use Frailty Assessment Tools to identify patients from your case load. You may use the Frailty Screening Tool or refer to this document for other frailty screening tools and information.

Your total enrolment number will be determined by the PHN Representative. You will be given a minimum and maximum number of patient enrolments per Practice per 12-month period.

Retrieving your patient list from NSLHD data using RoH score:

  • You may have received your patient list through your secure messaging platform Argus as a patient named ‘Keeping Well and Independent’.
  • Or through the secure email portal. Instructions are here. Your PHN representative or KWIP Care Coordinator can assist you in retrieving this if you do not have access to it.