Teresa’s Turnaround through Connected Care
General Practitioners and Social Workers collaborate to improve lives in Sydney’s North
GP Social Work Connect program client
Teresa Caruso, a 62-year-old mother of two, grandmother of three and wife to partner Frank, couldn’t get off her couch. Outside her home, in the suburbs of Northern Sydney, the local community was largely unaware of Teresa’s difficulties.
Teresa’s health condition had deteriorated over time. Her physical and mental health complications resulted in days increasingly spent at home in the living room, watching television, with limited sunshine and social interaction except with her immediate family. Frank, Teresa’s husband of almost 40 years, had become her full-time carer. “Frank does all the cooking and cleaning. He’s a very good man,” says Teresa.
GP Social Worker at PCCS
Teresa and Frank Caruso
Teresa and Frank have been married for almost 40 years
Senior Care Coordinator for GP Social Work Program at CCNB
As Teresa’s health declined, she decided to reach out to her General Practitioner (GP). Besides attending to Teresa’s immediate medical needs, the GP recommended a more holistic care approach for Teresa, referring Teresa to the “GP Social Work Connect” program. This program is delivered by not-for-profit local health organisation Primary & Community Care Services (PCCS) and commissioned by the Sydney North Primary Health Network on behalf of the Australian Government.
Sarah Melvin from PCCS was appointed Teresa’s social worker. “Working in partnership with Teresa’s GP, I am here to help Teresa and her family navigate the complex social services sector – helping her to be more independent and socially active. Working with her GP, I am addressing psycho-social issues, helping to resolve these with personalised support, and helping Teresa access complimentary services in the local community and beyond.”
“If a patient goes to a GP with particular health and medical issues, the GP may identify the GP Social Work Connect program to better support the patient and send us a referral. Once we receive the referral, we allocate a social worker to the patient. We then meet with the patient at their home to talk about addressing their needs and develop an action plan together. It is a step by step process that closely involves the referring GP. By working as one team, the GP and myself – as well as other members of the extended care team as needed – are better able to provide the right information and help patients to access the right social services and supports in their local community. The GP Social Work Connect program runs for eight weeks and PCCS regularly updates the GP via securing messaging services on the patient’s progress during that time,” says Sarah.
Sarah is passionate about the program, having seen the positive results. “When I first came to meet Teresa, she told me she never left the house. So, one of my suggestions was to help her to access and participate in local community activities. Originally Teresa resisted the idea, but after six weeks of working together, I now receive phone calls from her about what social groups and activities she might be able to attend next. Teresa is much more confident, social, and wanting to get out and about and try new things. We have also just received the news that Teresa will now receive the Disability Support Pension which we have been working on together. Her husband Frank needs a break from time to time as well, so we are working on getting a carer’s allowance for him.”
For Teresa, things have changed for the better, she says, “As a result of my GP and Sarah working as a team, my health has improved. I feel more alive, I feel better, and life is beautiful again. Thanks to my GP and Sarah, Frank and I go out most mornings walking, shopping, watching people and enjoying a cappuccino. With the social groups I have joined I have been able to talk to more people, go to dinner at the local club, visit Sydney Harbour, and see the Christmas lights.”
As a husband, grandfather, loyal Manly Sea Eagle’s fan and carer, Teresa’s husband Frank wears many hats. He is clearly thankful for the assistance the GP Social Work Connect program has delivered. “I do most of the cooking, cleaning and take Teresa to all of her appointments. It’s easier now. This service has helped us so much!”.
Teresa’s life has turned around, moving from being socially isolated and suffering from poor health, to a more healthy, independent, and socially active member of the Northern Sydney community.
“The idea of the GP Social Work Connect program is for the GP to focus on the health and medical needs of the patient, and refer to the social workers to assist with social services needs. These may include the National Disability Insurance Scheme (NDIS), My Aged Care, Centrelink, Department of Housing, community transport, helping people who have become dependent on drugs or alcohol, or even supporting carers suffering from stress and burnout. It’s coordinated care in action,” says Cynthia Stanton – General Manager, Primary Care Advancement and Integration, Sydney North Primary Health Network.
Sydney North Primary Health Network, an Australian Government funded initiative, established the GP Social Work Connect program in response to its 2016/17 local area health needs assessment. This annual population-level assessment identified people with chronic disease, dementia or who are ageing as having a potentially greater risk of lower health outcomes in certain settings, and a higher need for acute care intervention and hospitalisation.
The GP Social Work Connect program has helped the more vulnerable members of the Sydney North local community achieve better health and care where and when it is most needed. At the end of December 2017, the program had assisted 304 patients who were referred by 195 General Practitioners.
Teresa and her husband Frank Caruso
GP Social Work Connect program client
“As a result of my GP and Sarah working as a team, my health has improved. I feel more alive, I feel better, and life is beautiful again. Thanks to my GP and Sarah, Frank and I go out most mornings walking, shopping, watching people and enjoying a cappuccino.”
Primary Care Advancement & Integration Manager, SNPHN
“Sydney North Primary Health Network identified a gap in providing social work services to members of the Northern Sydney community and then linking them to General Practice.”
GP Social Worker at PCCS
“Working in partnership with Teresa’s GP, I am here to help Teresa and her family navigate the complex social services sector – helping her to be more independent and socially active.”
The Sydney North GP Social Work Connect program is delivered by the following not-for-profit organisations:
Primary & Community Care Services (PCCS) covering Hornsby, Ku-ring-gai, Ryde and Hunters Hill.
Phone: (02) 9477 8700 and ask for the GP Social Worker
Website: Complete a GP Social Worker Connect Referral Form available from and fax to 1300 067 747.
Note: All referrals will receive a confirmation via secure messaging (GPSocial).
For more information on the GP Social Work Connect program including eligibility criteria and how GPs can make a referral please click here.