COVID-19 care pathways

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

Page last updated: 5:00pm, 8 December 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 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.

West Metro COVID-19 Care Pathway

Please note that we previously referred to this pathway as the North West Melbourne COVID-19 Care Pathway.

A care pathway for patients who are COVID-19 positive is active in the western metropolitan region of Melbourne. This pathway began in a pilot phase from 3 August 2020. This pilot informed the statewide guidelines for management of COVID-19 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, supported by PwC. Western Health, Djerriwarrh Health Services, Mercy Health, the Royal Children’s Hospital and Monash Health 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. These patients are cared for by GPs using telehealth.
  • Medium risk patients are being cared for by the Hospital in the Home (HITH) programs of the health services listed above.
  • High risk patients are cared for by RMH. High risk pregnant patients are cared for by Monash Health.

Our Primary Health Care Improvement team is contacting GPs who have patients enrolled in the pathway to provide support and access to useful resources and tools.

Please watch the video with our GP Advisor Dr Jeannie Knapp for a summary of the most important information about this pathway. More information for GPs and care providers is available in the documents below the video.

https://www.youtube.com/watch?v=h8uwAinYJoU
West Metro COVID-19 Care Pathway: important information for GPs. Please note patient handovers to GPs are in writing only, and COVID Monitor has now replaced REDCap for patient monitoring.

Resources for the West Metro COVID-19 Care Pathway

  • COVID Monitor

    What is COVID Monitor? 

    COVID Monitor has now replaced the REDCap system for patient monitoring.

    COVID Monitor is a secure, online portal that allows you to view all of the patients enrolled in the model from your practice in one, clear dashboard. It has self-reported symptom monitoring for patients that will reduce the burden on GPs needing to call patients every 2 days.  

     Access COVID Monitor.

    COVID Monitor allows practices to:  

    • view a list of COVID-19 positive patients associated with your practice – those in low-risk GP care but also visibility of those in the medium and high risk categories
    • see individual patient details including timelines (such as swab date) and symptom history 
    • set up scheduled follow up if required  
    • request discharge from program  
    • enter symptoms on the patient record as part of your consultation (a PDF is available for upload into your clinical documentation system or you can cut and paste directly into clinical notes)   
    • view patient reported symptoms (if a patient chooses to enter them – they are sent a daily reminder) .

    Access to the system 

    Access to the system is by 2-factor authentication (an email and password then a secure pin). To ensure that all practices are able to access the system we are setting practices up with a generic log in, using a practice email that can be used from go live. 

    It is strongly encouraged that each user at the practice (GPs, nurses, practice managers) who is involved in managing and coordinating care for COVID-19 patients registers with a unique log in. This will allow the secure PIN to be sent to individual emails, and allows for any notifications about patients to be sent by SMS.  

    Training and support 

     General Practice User Guide (.pdf)

    Instructional videos

    Helpdesk

    For technical issues, problems logging in, to add new users or for any other queries please contact our COVID Monitor Helpdesk on (03) 9347 1188 or email primarycare@nwmphn.org.au 

  • Local Public Health Unit Map

    The LPHUs provide a new statewide system of public health delivery and oversight. They include key health service organisations working together to achieve a strategic and supportive approach to COVID-19 contact tracing, care pathways and vaccination.

    View map of the LPHU

  • Information flow

    cohealth will be notified of a positive test result in the north west region by the local Public Health Unit.

    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, the GP will receive a written handover 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 (.pdf).

  • 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: primarycare@nwmphn.org.au

Other pathways in our region

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.