GPs
Refer patients who may benefit from community nursing, post-hospital support, personal care or additional assistance at home.
GP referralsFor Referrers
A local care team you can refer to with confidence
SA Community Support works with GPs, hospitals, discharge planners, allied-health professionals, care coordinators and other health professionals to support people at home.
We provide Support at Home services and community nursing across Metropolitan Adelaide, Adelaide Hills, Barossa and Clare Valley.
Our focus is simple:
Understand the person's needs. Provide appropriate support. Communicate with the people involved in their care.
Choose your pathway
Who can refer?
Hospitals and discharge planners
Refer people who require appropriate support or nursing care after returning home.
Hospital & discharge referralsAllied-health professionals
Refer clients who may require additional nursing, personal care, community access or practical support alongside their existing allied-health services.
Allied-health referralsCare coordinators
Discuss clients who require additional support to remain safe, independent and connected at home.
Care coordinator referralsOther health professionals
If you are involved in someone's care and believe community-based support may help, contact our team to discuss the appropriate pathway.
Talk to our teamWhat can we help with?
When to consider a referral
A referral may be appropriate when a person:
- Requires nursing care at home
- Is returning home after hospital
- Has a wound requiring ongoing care
- Requires medication support
- Has continence or catheter needs
- Requires diabetes management
- Needs PEG or enteral feeding support
- Has ongoing chronic health needs
- Requires assistance with personal care
- Is struggling with everyday activities
- Has increased support needs following a change in health
- Needs help remaining independent at home
- Has family or carer support needs
- Requires additional community-based support
Every referral is considered according to the person's individual circumstances, clinical needs, approved arrangements and available services.
The process
What happens after you refer?
1. Referral received
Our team receives and reviews the referral information provided.
2. Information clarified
Where necessary, we contact the appropriate person to clarify the referral, current services, needs and next steps.
3. Pathway confirmed
We identify the appropriate service pathway based on the person's circumstances, approved arrangements and service requirements.
4. Assessment and planning
Where nursing assessment or other assessment is required, the appropriate professional completes the relevant assessment and contributes to care planning.
5. Services commence
Once the appropriate arrangements are confirmed, agreed services can commence.
6. Ongoing communication
Where appropriate and authorised, we communicate with relevant members of the person's healthcare team and respond to changes in needs.
Referral information
What information helps us?
The more useful information we receive at referral, the easier it is to understand the person's needs.
Where available, please provide:
Client information
- Full name
- Date of birth
- Address
- Contact details
- Preferred contact person
Referral information
- Reason for referral
- Services required
- Urgency
- Current concerns
- Relevant goals
Clinical information
- Diagnoses
- Current clinical issues
- Recent hospital admission or discharge
- Medication information
- Wound information
- Continence or catheter requirements
- Diabetes information
- PEG or enteral feeding requirements
- Relevant clinical observations
Current care
- Existing Support at Home arrangements
- Current service providers
- GP details
- Allied-health professionals
- Relevant care plans
- Discharge documentation
Supporting documents
Where appropriate and authorised, relevant clinical or care documentation can be provided with the referral.
What you can expect from us
Professional communication
We aim to communicate clearly and respectfully with the people involved in the person's care.
Local responsiveness
Our team is locally based and focused on practical, timely service.
Clinical leadership
Community nursing services are supported by experienced nursing leadership.
Person-centred care
We respect the person's dignity, privacy, choices, independence and goals.
Appropriate escalation
Changes or concerns identified during care are managed according to the person's needs, clinical responsibilities and applicable procedures.
Genuine relationships
We believe effective care depends on strong relationships between clients, families, carers and healthcare professionals.
Supporting hospital-to-home transitions
A successful discharge does not end when the person leaves hospital.
People may return home with:
- New medications
- Wounds
- New diagnoses
- Reduced mobility
- Changed continence needs
- New equipment
- Increased personal-care requirements
- New clinical monitoring needs
- Increased family or carer demands
Our team can discuss the appropriate community support pathway.
GP referrals
Community support and nursing for your patients at home
SA Community Support works alongside GPs to provide appropriate Support at Home and community nursing services for people living in the community.
We can support patients who require:
- Community nursing
- Post-hospital nursing
- Wound care
- Medication management
- Diabetes management
- Continence and catheter care
- Chronic health support
- PEG and enteral feeding support
- Personal care
- Daily living assistance
- Community access and social participation
Where appropriate and authorised, we can communicate relevant information with the patient's healthcare team.
Information that helps
Referral reason, relevant diagnoses, current medications, recent hospitalisation, clinical concerns, current services and any relevant care documentation.
Hospital & discharge referrals
Helping people transition from hospital back home
Returning home after hospital can create new clinical and practical challenges.
SA Community Support can discuss appropriate community nursing and Support at Home pathways for people who require additional support following discharge.
We may assist with:
- Post-hospital nursing
- Wound care
- Medication support
- Continence and catheter care
- Diabetes management
- PEG and enteral feeding support
- Personal care
- Daily living support
- Transport and appointments
- Community access
- Ongoing support at home
Referral information
Where available, please provide the discharge summary, medication information, relevant clinical documentation, current support arrangements and the person's immediate support needs.
Allied-health referrals
Supporting the work of the broader healthcare team
SA Community Support works alongside allied-health professionals to help clients receive appropriate support in their home and community.
Our services may complement recommendations from:
- Physiotherapists
- Occupational therapists
- Speech pathologists
- Podiatrists
- Dietitians
- Other allied-health professionals
Depending on the person's needs and approved arrangements, support may include nursing, personal care, daily living assistance, community participation, transport and other appropriate services.
We value clear communication, respect professional roles and recognise that good outcomes often depend on coordinated care.
Refer a client
You can make a referral online or contact our team directly.