How to Refer

Who can refer?

  • Nursing and Allied Health providers,
  • General Practitioners
  • Specialists
  • Patients who have previously been enrolled with Chronic & Complex Care can self-refer should they need more care.

How do I refer?

  1. Complete the Referral Form in full.
    Referrals must include:
    • Reason for referral and relevant medical history
    • Patient phone number and identifying information (carer contact details to be provided if more appropriate)
  2. Attach all relevant documentation e.g. pathology / imaging / specialist reports
  3. Email to SHVS.chroniccomplexcare@svha.org.au
  4. Flag urgent referrals clearly in the subject line

Patient Eligibility:

Referral Criteria

Patients must meet the following criteria:

  • 16 years of age or older
  • Lives within the St Vincent’s Community Catchment Area (link)
  • Covered by Medicare or eligible for reciprocal rights
  • Has a GP or is willing to engage a GP
  • Consents to referral and willing to engage in a goal-directed, time-limited care plan
  • Diagnosed with a chronic or complex health condition (e.g., COPD, heart failure, diabetes, osteoporosis, neurodegenerative disease)
  • Rising-risk or unstable health trajectory (risk of avoidable hospitalisation or deterioration)
  • Requires short-term, intensive intervention (for stabilisation, self-management, or safe discharge)
  • Clinically stable with defined health goals
  • Not currently receiving equivalent case management from another multidisciplinary team

Additional priority factors:

  • Frequent hospitalisations or emergency department presentations
  • Recently discharged from hospital and at risk of readmission
  • Barriers to accessing traditional care models (e.g., mobility, cognitive, or social challenges)
  • Complex medication or treatment management needs

Not sure? Please call us

We understand that many patients have complex and overlapping needs.
If you're unsure whether your patient is eligible, call our team to discuss.
We’re happy to provide advice, explore shared care options, or direct referrals to more appropriate services if needed.

Referral contact details:
Call: 0418 175 313  Email: SHVS.chroniccomplexcare@svha.org.au