What is the GP Social Work Program?

The GP Social Work Program is a hospital avoidance program commissioned by the Sydney Northern Primary Health Network supporting people to stay well and healthy in their chosen community.

A GP can refer anyone to the service including:

• People with high and or complex care needs requiring support from a range of community care providers.
• Carers at risk of stress or burnout – requiring support and assistance in their caring role.
• People who have difficulty navigating and accessing support services e.g. the NDIS or aged care service system.
• Anyone who has had a recent and or recurrent hospitalisation due to care and support needs.
• People with complex family situations including family and domestic violence.
• People with alcohol or substance abuse dependency.
• People who may be experiencing loneliness and isolation.
• People who may hoard or live in squalor.

The program exists to support GPs to provide holistic care to their patients.

Our Social Workers will work with individuals and their families to develop a set of goals, and support them to link to appropriate services and supports to meet those goals.

How to access the program?

GPs and practice staff can refer patients to the GP Social Work Team at CCNB.
We can arrange for a Social Worker to meet patients in the general practice environment, or follow up at a convenient time in their home or community.

Make a referral
Patricia* is a 73 year old lady who lives in her own unit. CCNB was alerted to Patricia’s situation by a geriatrician from Mona Vale Hospital. Patricia had alcohol dependence and was struggling to manage independently at home, living in a squalid environment. Patricia was cycling in and out of hospital and was not responding very well to services. Patricia has a son who has a history of financially abusing her.

Patricia was not linked with a GP as she could not mobilise independently from the house and her old GP did not home visit. The Social Worker earned her trust and commitment to go ahead with a linkage to a home visiting GP. The GP was instrumental in maintaining a relationship with Patricia and following up on her needs.

With funds from the GP Social Work Program, Patricia was able to access pest control, occupational therapy and some home modifications.

Patricia has now been linked with ongoing home services through a Home Care Package at CCNB. The Social Worker and Home Care Package Care Coordinator offered Patricia support in taking a stand against her son who has been abusing her.

Patricia did not give permission for the staff to alert authorities, so with the support of the Specialist Mental Health Service For Older People, a Guardianship application has been submitted for financial management.

* The name has been changed to protect the privacy of the individual.

Shirley* is a 61 year old woman who lives with her partner in a boarding house. Shirley was referred to the GP Social Work Program after it became evident that her cognition had deteriorated rapidly. Her poorly managed diabetes had resulted in Younger Onset Dementia.

Shirley was forced to cease work, managed finances so badly that they lost their rental property and did not have stable income apart from her partner’s part-time entry level job.

Shirley’s mobility began to deteriorate and her partner began to experience severe carer stress.

The Social Worker has been able to work with Shirley and her partner to apply to and access the NDIS. Shirley now has a large package of money to support her in most daily living tasks and offer her partner a break from caring for her.

Shirley was able to access her superannuation, apply for the Disability Support Pension and her carer was able to apply for and start receiving the Carer’s Pension.

After completing an application for Housing NSW, the Social Worker also supported them to link with Mission Australia to receive support in looking for more appropriate housing.

Shirley and her partner felt they could not navigate the various systems themselves and feel they have been able to achieve outcomes and receive support they did not know was available.

* The name has been changed to protect the privacy of the individual.