COVID-19 care pathways

Primary care management of COVID-19 patients in our region.

Page last updated: 9:30am, 21 January 2021

Background information

The COVID-19 Positive Care Pathways program is the Victorian statewide program for assessment and management of COVID-19 patients.

Public hospitals, primary and community health care providers, Primary Health Networks and GPs offer pathways that are relevant and responsive to each local service system and population.

The Victorian Department of Health and Human Services has provided a fact sheet for referrers (.pdf) that contains more information about the program plus contact details for the intake and assessment services across Victoria. Clinicians may wish to use this information to get in contact with other pathways programs to either:

  • refer patients who are known to you but reside in another catchment area; or
  • to follow up on patients known to you. For example: a confirmed case (from being a close contact of a current patient) who you wish to confirm is in a care pathway.

North West Melbourne pathway

A care pathway for patients who are COVID-19 positive is active in the north west region of Melbourne. This pathway began in a pilot phase from 3 August 2020 and supports continuity of care with patients’ usual general practice. Clinical and referral information is available on HealthPathways Melbourne.

The pathway was co-designed by the Royal Melbourne Hospital (RMH), cohealth, North Western Melbourne Primary Health Network (NWMPHN) and the Victorian Department of Health and Human Services (DHHS), supported by PwC. Western Health, Mercy Health and Djerriwarrh Health Services have also joined this pathway.

The pathway is designed to provide safe, high quality care, including community-based care for low risk COVID-19 positive patients, with escalation mechanisms to higher levels of care if required.

  • Low risk patients are defined in the model as those who have no or mild symptoms and no risk factors.
  • Medium risk patients and high risk patients are cared for by RMH.

Our Primary Health Care Improvement team is reaching out to GPs who have a patient enrolled in the pathway to provide support and access to useful resources and tools.

The following information relates to the North West Melbourne pathway between DHHS, the Royal Melbourne Hospital, cohealth, NWMPHN, Western Health, Mercy Health and Djerriwarrh Health Services:

  • Information flow

    cohealth will be notified of a positive test result. Initially this will only apply for patients who had a COVID-19 test at RMH or a cohealth testing site.

    On notification of a positive test result, cohealth will contact patients to:

    1. gain consent to be managed through the pathway
    2. perform a clinical assessment and risk stratification
    3. perform a social and welfare needs assessment.

    If the patient nominates a usual GP, cohealth will phone the GP to notify them of:

    • the positive result for your patient
    • the outcome of the clinical assessment
    • the patient’s current risk category (low, medium or high).

  • Role of the GP

    GPs are asked to perform telehealth check-ins with all low risk COVID-19 positive patients. All telehealth consultations will be bulk billed and funded through MBS, as per the MBS guidelines.

    The monitoring period for COVID-19 positive patients is 14 days. More details regarding call frequency is available in the model overview.

  • Resources

  • HealthPathways Melbourne

  • Feedback and questions

    We are keen to hear from practices who have feedback, concerns or queries about how the model is working for you and your patients. Please email us: covid@nwmphn.org.au

Other pathways in our region

  • North east Melbourne (Austin Health)

    As per a recent DHHS directive, received in August, Austin Health are coordinating an integrated program for managing COVID-19 patients in Melbourne’s north east in collaboration with local GPs and community health services.

    Overview

    • Daily, the DHHS will provide Austin Health with a list of newly diagnosed COVID positive patients in the Nillumbik, Darebin and Banyule local government areas.
    • Austin Health clinicians will make initial contact with the patient, explain the program and obtain the necessary consent for them to participate. They will then risk stratify the patient into the low, medium or high risk pathway based upon a standardised assessment, with anyone stratified into the low risk pathway eligible for management by the patient’s nominated or preferred GP, or a GP within community health services.
    • Austin Health will contact the nominated GP of a patient who has been risk stratified into the low risk pathway to perform a clinical handover.
    • Austin Health are using the CovidCare online tool to support monitoring of patients in primary care and will provide details of how to use this tool when contacting GPs. The GP will then be responsible for the medical management of this patient.
    • Local community health services will perform social and welfare assessments and subsequent management of all patients, irrespective of which pathway they have been stratified into.
    • The community health services are Banyule Community Health, Carrington Health/HealthAbility and Your Community Health.
    • Austin Health will manage de-isolation and discharge from the pathway.
    • Visit HealthPathways Melbourne for more information on this pathway.

    Feedback

    We are keen to hear from practices who have feedback, concerns or queries on how the model is working for you and your patients. Please email us: covid@nwmphn.org.au

Please note: Other health services in the NWMPHN region are also in the process of developing or have developed models to care for patients in their local region. Visit HealthPathways Melbourne for up-to-date clinical and referral information on the different pathways.

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