SWSPHN is commissioning the COVID-19 Monitoring Project through which registered nurses (RNs) employed at participating ‘keystone’ practices in South Western Sydney manage COVID-19 positive patients from across the region.
What is the project?
The COVID-19 Monitoring Project is a six-month pilot project.
The project includes keystone practices delivering an innovative model of care through which practice nurses will monitor COVID-19 positive patients from across South Western Sydney who have been referred by non-participating practices.
All general practices in South Western Sydney are invited to refer their COVID-19 positive patients to the project to be managed by registered nurses (RN) for the duration of their diagnosis (for example, seven to 14 days).
The project aims to alleviate the workload on GPs, and promote the skills and capability of RNs to provide telehealth care.
How will it work?
GPs not participating in the project will refer patients through a centralised intake process managed by SWSPHN.
The RN will provide technology-based consultation to both Medicare eligible and ineligible patients as Medicare details will not be required for the project
GPs must gain patient consent before referring them to the project.
Who is eligible to participate?
Only patients from South Western Sydney’s seven local government areas (Wingecarribee, Wollondilly, Camden, Campbelltown, Liverpool, Fairfield and Bankstown) are eligible to participate in the project.
Participants should not exceed low-to-medium risk management. If there is a patient who is requiring escalation, they will be referred to a GP within the keystone practice or back to their referring GP.
How does the process work?
As soon as a referral has been taken, the RN will:
- Enter the patient’s details into Inca – this may be basic, for example, full name, DOB, contact details, significant clinical history (for example, allergies, chronic conditions etc)
- Contact the patient, confirm identity, introduce themselves, establish the best time to provide the telehealth service, provide them with information about logging into Inca, email details to them
- Contact the Translating and Interpreting Service if required
- Ensure the patient understands their COVID-19 diagnosis and their isolation requirements
- Go through the Inca COVID-19 specific clinical questions with the patient
- Provide information about the frequency of calls to be expected after establishing the patient’s risk level. Most low-risk patients who register with the Inca platform and complete the questions each day will only need to be called again at the end of their illness
- Once the patient has registered with Inca, they will receive a set of questions to respond to each day. The RN will then be able to see the responses to these questions for each patient and will be able to identify if any patients require phone follow up
- Elderly patients, CALD patients or patients with barriers to accessing technology may not be comfortable accessing the Inca platform. In these cases, the RN will contact the patient more frequently to undertake monitoring. The RN will agree on a call frequency with the patient, based on their clinical need. The RN will enter responses to the questions into Inca against the patient’s file
- If at any time during monitoring the RN identifies a clinical emergency, they will advise the patient or their carer to contact 000 or do this on their behalf, and notify the GP in their practice or the referring GP
- If at any time during monitoring the patient’s COVID-19 symptoms worsen, or there are complications due to their chronic disease, the RN will consult the patient’s regular GP and consider escalation back to GP care
If your patient has any queries regarding self-isolation, including for their family members, you can refer them to the NSW Health webpage. They can also access the Healthdirect self-help tool.
What happens when the patient is discharged?
When the patient has been identified as ready to be discharged from the project (after seven to 14 days) or when they are clinically able to self-manage, the RN will enter a brief summary report into the patient’s file. This report will be sent to the referring GP, including a brief summary of the patient’s COVID-19 symptoms throughout the duration of their diagnosis.
How do I refer patients to the project?
Download the COVID-19 Monitoring Project Referral Forms:
COVID-19 Monitoring Referral Form – PDF
COVID-19 Monitoring Referral Form – BP
COVID-19 Monitoring Referral Form – MD
What if I have questions?
Email SWSPHN’s COVID-19 Response Team at covid19@swsphn.com.au with questions about the project.
Download the COVID-19 Program Monitoring Toolkit for keystone practices.