All services listed below except the Geriatrician Outreach to Primary Care Service are listed in HealthPathways. On HealthPathways you will see eligibility and referral information for all services. Please use your HealthPathways log in to access the details. If you require a login or information on HealthPathways please see this page on HealthPathways access.

Listed by type:


Not suitable for urgent acute issues

Geriatrician outreach to Primary Care Service

The Geriatrician Outreach to Primary Care service has no formal referral form.

The service typically can do the following:

  1. Practice visits to GPs
  2. Joint Consults with the GP and the Patient
  3. Geriatrician can liaise with other hospital outpatient/inpatient clinics
  4. Patient Assessments at practice or Home Visits
  5. Provide general advice via phone, email

Service name: Geriatrician Outreach to GP Service

Provider: NSLHD Geriatricians (Free service and priority reserved for KWIP Patients)

Description: Able to provide GPs with online or in person advice on medication management, frailty, cognition impairment, falls, depression, and other age-related issues and more.

Available: Monday to Friday, 9:00am – 5:00pm

Ryde/Hunters Hill Area
Dr Linda Xu
0451 829 527

Lower North Shore Area
Dr Praveen Sivabalan
0434 579 132

Dr Alexandra Annesley and Dr Charmere Linton
0478 784 215

Urgent Service

Suitable for acute issues

Rapid response

Preventative and Post Discharge Service

GP social work service

Preventative and semi-acute

Suitable for patients post discharge however not urgent or acute cases

Hospital in the Home (HITH)


Suitable for access to social support services and allied health

Healthy Ageing Services

Community Transport Provider: Provides free transport services for older patients to access community and primary care services across the entire Northern Sydney region.

Early Intervention PACE Program: The PACE program is available to provide individual support and critical information to clients about their diagnosis, symptoms and to connect them to the right services and community groups that enable healthy ageing and management of chronic conditions. It is available to access until 30 June 2024.


Suitable for patients with Dementia



Suitable for patients with chronic and complex social and health care needs

Chronic and Complex Care Nurses

  1. Name of service: Chronic and Complex Care Service
  2. About: The Chronic and complex care coordinators facilitate self-management skills for people with chronic and complex needs in the community over a 12 week program.
  3. When to refer: For people residing within NSLHD, aged over 16 years old with complex clinical and/or social needs, and an increased risk of unplanned hospital admission, that would benefit from multidisciplinary care planning, education and support in the community.
  4. Who can refer: Anyone – self referrals, GPs, community nursing, specialists, etc.
  5. Referral Details:
    Phone: 1300 732 503
    Business Hours: 8:00am—4:30pm | Monday to Friday

Preventative and semi-acute

Suitable for patients post discharge however not urgent or acute cases

Northern Sydney Home Nursing Service (NSHNS)


Non-acute Geriatrician Support Services (Different to the Geriatrician Outreach to Primary Care Service)

Geriatrician Outpatient Clinics

Other Geriatrician Support (Different to the Geriatrician Outreach to Primary Care Service)


Navigation and information support

Care Finder

The Northern Sydney care finder service is delivered by Your Side and makes up part of a national network of care finders. Their role is to perform assertive outreach and support vulnerable older people to register for My Aged Care and to connect with aged care and other types of health and community care services. The program is designed for people who require intensive one to one support in order to access services.

Your Side care finder intake:
Care finder information
(02) 8405 4484