Hornsby Ku-ring-gai Health Service: Caring for a healthier community

Your health: Information for health professionals
Referring a patient to Healthy at Home



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What is Healthy at Home?

Healthy at Home is designed to support older people (aged 65 years or older or 45 years for Aboriginal and Torres Strait Islander people) whose medical condition is starting to decline. It is intended to stop further deterioration and improve older people's conditions before they become too unwell and need to go to hospital.

When should you refer a patient to Healthy at Home?

This fact sheet is intended for health professionals who wish to refer clients who live in the Hornsby or Ku-ring-gai local government areas. However the program is also available through John Hunter Hospital, St George Hospital and Queanbeyan Hospital: for more information check the NSW Health website.

Hornsby Ku-ring-gai Health Service participates in the Healthy at Home program. It is currently available to patients who meet the following criteria:

  • 65 years of age or older (45 years and over for Aboriginal and Torres Strait Islander peoples)
  • Living in the local government areas of Hornsby or Ku-ring-gai
  • When you suspect the person is at imminent risk of needing to go to hospital and
  • when there is the onset or deterioration of one or more of the following:
Mobility Recent fall and/or change in ability to walk.
Memory Confusion or increasing forgetfulness - usually noticed by a carer, relative, or a neighbour.
Everyday tasks A change in doing usual every day tasks, such as
  • Washing themselves is difficult
  • Not changing clothes
  • Not getting to the toilet in time/soiling clothes
  • Unable to prepare a meal
Carer needs The carer notices an increase in the needs of the care recipient and feel they are unable to cope in meeting these needs
Deterioration in health
  • Shortness of breath
  • Swollen limbs
  • Dizzy spells
  • Lack of interest in food/loss of appetite
  • Increased tiredness
Home environment Neglected home environment, e.g. rotting food in fridge, soiled sheets
Community Services Need for extra or ad-hoc community support in recent weeks.

Adapted from the Healthy at Home information on the NSW Health website.

How to refer:

Referrals can be made by phoning 1800 152 149 or by faxing a GP referral form to 4925 7950. The referral processes takes approximately to 5-10 minutes. You need to provide information about the person needing the service, for example their name, address, date of birth, next of kin and reason for referral. Before you call please have the following information on hand:

  • Patient details - name, address, contact details
  • Patient's Medicare Card No.
  • Country of birth and preferred language spoken
  • Reason for referral
  • Diagnoses & current problems
  • CDM items

We have more information on Healthy at Home at HKHS. Hornsby Ku-ring-gai Health Service also has a wide range of community health, rehabiltation and aged care services, including bone density screening, gentle exercise classes and weight control programs. Contact details for our Rehabiltation and Aged Care Service are on this website.

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© Hornsby Ku-ring-gai Health Service

Last updated 15 January 2009

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