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Outpatient and community services

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Outpatient services

​Outpatient care is provided in specialist palliative care outpatient clinics by members of the multi-disciplinary supportive and​ palliative care team from HammondCare and NSLHD.

Outpatient clinics are available across Northern Sydney to help support people with palliative care needs who are well enough to attend clinics. Reasons for referral include complex symptom control and early linkage with supportive and​ palliative care services.​​

 Royal North Shore outpatient clinics

​Eligibility and referrals

RNSH outpatient clinics accept referrals for patients residing in NSLHD from GPs, inpatient and outpatient services, when community care is not yet required but people have ongoing specialist supportive and​ ​palliative care needs.

There are three palliative medicine clinics based at RNSH occurring on Wednesday, Thursday and Friday.

  • Email referrals to
  • Referrals must include:
    • Diagnosis
    • Past Medical History
    • Medications
    • Relevant investigations
    • Patient aware of the referral
    • Mobility status
    • Other specialists/GP
    • Reason for referral (e.g. symptom management, advanced care planning, psychosocial support)
    • Urgency

A Nurse Practitioner led palliative care oncology outpatient clinic based at RNSH supports patients with supportive and palliative care needs.
Referrals can be made via

 Other supportive care clinics

​Cardiac Supportive Care  

The aim of the Cardiac Supportive Care Service is to provide a co-ordinated approach between cardiology and supportive care for adult patients living with advanced heart failure within NSLHD. The service consists of a Nurse Practitioner that provides a link between cardiology and supportive care services.

The Nurse Practitioner can see patients in outpatient clinics at RNSH, Hornsby and Ryde Hospitals or a home visit appointment.

The Nurse Practitioner works independently and collaboratively with other healthcare teams to provide comprehensive services, which include:

  • Assessment and diagnosing your health problems
  • Management of the symptoms of end-stage heart failure i.e. shortness of breath, ankle or abdominal swelling, increased tiredness
  • Medication reviews
  • Referrals to other health professionals and services
  • Education
  • Psychosocial support
  • Advanced care planning

Find more information aboutExternal Link​cardiac supportive care service here.

Renal Supportive Care   

Renal supportive care is part of the extended services provided by the renal services based at RNSH and Hornsby Hospital.

There are weekly clinics based at RNSH and monthly clinics based at Hornsby Hospital.

To refer to renal supportive care, a referral must first be made to a nephrologist at RNSH or Hornsby Hospital as outlined by Renal Services.

Find more information aboutExternal Linkrenal supportive care service here.

NSLHD Supportive and Palliative Care Occupational Therapists 

NSLHD Supportive and Palliative Care Occupational Therapists​ work with the multi-disciplinary team to support patients in the transition from hospital to home for end-of-life care. They work in collaboration with inpatient Occupational Therapists to determine functional status and patients’ needs for discharge.

Palliative Care Occupational Therapy assessment and interventions are provided specific to palliative/end of life care which could include:

  • Home assessment prior to discharge
  • Home visit after discharge
  • Education for patients and families in their home environment, for example, manual handling, pressure care, positioning, energy conservation and fatigue management, falls prevention and safe use of equipment.
  • Carer training in the home environment.
  • Basic home modifications.
  • Review of additional equipment needs post discharge.

Criteria for referral is that the patient has been referred to the inpatient palliative care service. Referrals can be made through the Palliative Care team or directly from hospital Occupational Therapists. 

​​Community services

Community supportive and​ palliative care is delivered collaboratively by HammondCare, Northern Sydney Home Nursing Service and other supportive and palliative care services.
The aim of these services is to provide supportive and​ ​palliative care to all eligible patients in the community setting in partnership with the patient’s General Practitioner and primary health care providers.

Specialist multidisciplinary palliative care

HammondCare provides specialist community palliative care services and outpatient clinics within Northern Sydney. The services are delivered by a multidisciplinary team and are provided in the most appropriate setting for the patient to provide the right care to the patients in the right place at the right time.

The service provides:

  • Symptom management (physical, psychosocial, and spiritual)
  • Assistance with complex advance care planning
  • Support to facilitate end of life care in the community in collaboration with Northern Sydney Home Nursing Services
  • Hands on end of life care including management of subcutaneous medication (syringe drivers), support and education for carers
  • Carer support individually/groups
  • Bereavement support​​​

 Service delivery

  • ​Within 48 working hours of receiving completed a routine referral, HammondCare will undertake a telephone triage to ascertain eligibility, level and urgency of needs and to seek consent for service delivery
  • HammondCare undertakes an initial face to face assessment in either the clinic or community setting (home or RACF)
  • Following assessment, if the patient is deemed eligible for ongoing service provision, HammondCare will create a care plan including referrals to allied health and medical staff as required
  • If at any stage the patient is not deemed eligible for ongoing specialist community palliative care input, they may be discharged to the General Practitioner and if appropriate signposted to more suitable services for support in the community such as organ specific supportive services or general nursing support
  • After each meaningful clinical interaction, a letter will be shared with the referrer and General Practitioner to update them regarding the patient’s condition and suggested plan of care
  • If the patient requires additional support with end-of-life care at home or has other generalist nursing needs, the service may engage in a shared care model with Northern Sydney Home Nursing Service​

 Eligibility and referrals

  • The patient’s primary residence is in the geographical area of NSLHD and 
  • The patient is over the age of 18* and 
  • The patient has progressive life limiting or life-threatening illness (malignant and/or non-malignant) and 
  • The patient and/or substitute decision maker consents to referral to the service and one or more of the additional criteria below:
    • The patient has complex symptoms that require specialist assessment and management   
    • The patient and/or family has complex emotional, psychosocial or spiritual needs related to the life-limiting diagnosis and impacting on care in the community that require specialist multidisciplinary team assessment and management   
    • The primary care team and/or patient and care givers would benefit from support when undertaking complex future care planning  
    • It would not be a surprise if the patient died in the next 12 months and the primary care team requires additional support and /or advice in addressing complex needs    

Please note - Palliative Care may be provided in collaboration with Paediatric Palliative Care service for patients under 18 after consultation.

  • Referrals can only be triaged during business hours: Monday to Friday, 8am – 4:30pm
  • All referrals must be accompanied by a completedPDF iconreferral form faxed or emailed to the appropriate service (details are provided on the referral form)
  • Urgent referrals within business hours should be accompanied by a telephone call to 1800 427 255
  • Incomplete referrals may result in delays to clinical care

Further information:

Community Palliative Care Nursing

Northern Sydney Home Nursing Service focuses on the promotion of health and prevention of illness through community-based nursing care to people both within their homes and in clinic environments throughout Northern Sydney.

The service provides:

  • General palliative symptom support
  • Medication management
  • Oncology support such as symptom management during chemotherapy, education and support related to disease process or treatment of side effects such as management of drains, and central venous access devices
  • Drain ascites and pleural effusions via ports or indwelling catheters
  • Collaboration with the general practitioner and escalation in response to change in health status or new symptoms
  • Collaboration with HammondCare Specialist Community Palliative Care service for shared care for patients with complex needs
  • Hands on end-of-life care including management of subcutaneous medication (syringe drivers), provision of personal hygiene, support, and education for carers
  • Post bereavement visit​

 Service delivery (Community Palliative Care Nursing)

  • Northern Sydney Home Nursing Service provide an initial in-person assessment for patients
  • Following service admission and a comprehensive nursing assessment, Northern Sydney Home Nursing Service will send a letter electronically to the patient’s general practitioner outlining the plan of care
  • If specialist palliative care services are needed (and after discussion with the person’s general practitioner) the service will engage in a shared care model with HammondCare

 Eligibility and referrals (Community Palliative Care Nursing)

  • Patients of all ages requiring nursing intervention and living within the Northern Sydney catchment area.

  • Referrals are made via the NSLHD Health Contact Centre on 1300 732 503​
  • Northern Sydney Home Nursing Service operates 7 days a week from 8:00 to 4:30pm, with limited evening service
  • All patients must have medical supervision from either a medical practitioner or a hospital, and the patient will be asked to provide consent for the service to contact their General Practitioner and other relevant service providers when necessary

Further information:
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