KWIP Activities

Below is a list of the activities to support care delivery for KWIP patients during the 12 month period. The tasks can be completed by any member of the practice care team with oversight and instruction from the patient’s GP.

The tasks have been split into two categories of responsibility however please allocate these tasks to whomever is most appropriate as mentioned above.

Suggested staff to take responsibility:
GP/Nurse/Care Team
Suggested staff to take responsibility:
KWIP Care Coordinator

Regularly check your patient list and review patients for eligibility to be enrolled into the program.

Use of risk stratification to determine patient’s risk score. Consider using a combination of the Ministry’s RoH NSLHD data, Primary Sense and Frailty Screening tools to determine other appropriate patients.

Carry out risk stratification processes to help identify patients appropriate for the program.

Call patients that are suitable into the practice to see their GP.

If GP instructs complete consent form, EQ-5D-5L and Frailty Assessment tool (also in 12 months time).

Use the Frailty Assessment tool to then determine next steps for patient- referring to and completing the suggested steps in this decision tool.

Ensure the patient has the following things up to date or in place where appropriate/required:

  • Health Assessment/ GPMP or other care plans
  • vaccinations, including latest flu and COVID-19 vaccinations (offered)
  • Advanced Care Directives
  • Other key items for older persons health care management.

Schedule regular care plan update meetings for patient.

GPs are to refer to the Geriatrician as needed (this is not mandatory but encouraged).

KWIP Care Coordinator to ensure Practice is receiving letters and discharge summaries from local public hospitals in Northern Sydney. For issues contact NSLHD Health Information Services.

Connect and refer to appropriate external services.

Conduct home visits for patients that are enrolled into the program, if GP deems appropriate and urgent.

Demonstrate proactive care and more timely access (examples can include: dedicated appointment times for KWIP patients, rotating roster shared between GPs within the practice to support patients in need of urgent care, contact with patients post discharge in a timely way, increased frequency of GP appointments, nurse/administrator calling KWIP patients quarterly to ‘check in’ and see how they are doing). Note these are examples and are not mandatory but the Practice will need to demonstrate something that shows an improvement to access.

Any patient that is medium-very high risk to be contacted within 5 business days of patient being discharged from hospital.

Participate in quarterly support meetings with SNHN representative and the KWIP Care Coordinator.

Practices are encouraged to consider referring patients that are experiencing a functional decline and may require hospitalisation in 48 hours to ARRT, GRACE or BRACE.

Practices are encouraged to promote ARRT, GRACE or BRACE with families or carers of patients to use as an alternative to ED. Click here to download an information flyer.

Information on services will be found in the Services section of the KWIP web pages.