Aged Care Clinical Referral Pathways
Background
Primary Health Networks (PHNs) are funded to support the Australian Government’s response to the Royal Commission into Aged Care Quality and Safety.
SEMPHN has developed the Aged Care Clinical Referral Pathways to support health professionals provide advice, referrals and connections for older people into local health, support and aged care services.
These services are for people over 65 and Indigenous people over the age of 50 living in the South Eastern Melbourne PHN region. 3 hospital networks are located in the South Eastern Melbourne region, Alfred Health, Monash Health and Peninsula Health. These hospitals provide many health care services for older people, and can be provided in the hospital, the community, or in the home.
The services listed are intended to help health care practitioners identify the right service to refer their patient onto, and provide accurate contact details to enhance the referral process.
A file for each hospital network's referral pathways is available for download, but are also listed on this page.
Download the Referral Pathways
Alfred Health Aged Care Referral Pathways
Monash Health Aged Care Referral Pathways
Peninsula Health Aged Care Referral Pathways
Alfred Health Aged Care Referral Pathways
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Falls Clinic
Alfred Health Falls Clinic
Service Address: Ashley Ricketson Centre (Building 22) – enter through Gate 2
Caulfield Hospital
260 Kooyong Road, Caulfield, 3162
Email: gcgmcaccess@alfred.org.au
Website: Falls Clinic | Alfred Health
Phone: (03) 9076 6776 (Caulfield Access Unit)
Fax: (03) 9076 6773
Clinics:
Weekly on a Wednesday 9am-5pm (except public holidays)
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Geriatric & General Medicine in Older People Clinic
Caulfield Hospital, Main Block (Building 28), Level 1, 260 Kooyong Road, Caulfield, 3162
Phone: (03) 9076 6800
Website:Geriatric & General Medicine in Older People Clinic
Fax: (03) 9076 6435
Clinics:
Monday Morning & Afternoon
Thursday Morning & Afternoon
Friday Morning
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Hospital Admission Risk Program
Service Addresses:
Caulfield Hospital, 260 Kooyong Road, Caulfield 3162 VIC
The Alfred, 55 Commercial Road, Melbourne 3004 VIC
Sandringham Hospital 193 Bluff Road Sandringham 3191 VIC
Email: harpadmin@alfred.org.au
Website: Geriatric & General Medicine in Older People Clinic
Phone: (03) 9076 6776 (Caulfield Access Unit)
Fax: (03) 9076 6773
Referral enquiries: (03) 9076 6700
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Better at Home
Service Address:
Caulfield Hospital, 260 Kooyong Road, Caulfield 3162 VIC
Email: gemathome@alfred.org.au
Website: Better at Home | Alfred Health
Phone: (03) 9076 6336 or (03) 9076 6253
Fax: (03) 9076 4825
Opening Hours for inquiries: Monday - Friday 8:00am-4:30pm
Hours of operation for current patients: 24 hours, 7 days a week.
After-hours/emergency number: 0439 526 869
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The Cognitive, Dementia and Memory Service (CDAMS)
Service Address: Caulfield Hospital, Main Block (Building 28), Level 1, 260 Kooyong Rd, Caulfield VIC 3162
Email: gcgmcaccess@alfred.org.au
Website: CDAMS Website
Phone: (03) 9076 6010 (CDAMS Clinic) or (03) 9076 6776 (Caulfield Access Unit)
Fax: (03) 9076 4825
Referral Form: CDAMS Referral Form
Clinics:
CDAMS Clinic runs weekly on Tuesdays and Wednesdays 8:30am-5pm (except public holidays)
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Aged Community Mental Health Service
Service Address:
Caulfield Hospital, 260 Kooyong Road, Caulfield 3162 VIC
Aged Community Mental Health
Website: Aged Community Mental Health
Phone: (03) 9076 6012
After-hours call 1300 363 746
Baringa Aged Inpatient Mental Health
Website: Aged Inpatient Mental Health
Phone: (03) 9076 6396
After-hours call 1300 363 746
Referral fax: (03) 9076 6115
Clinics:
Aged Community Mental Health operates Monday – Friday: 8.30 am-5 pm (except public holidays)
Baringa operates 24 hours, 7 days a week.
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Carer Services
Service Address:
Caulfield Hospital, 260 Kooyong Road, Caulfield 3162 VIC
Alfred Health Carer Services
Phone: 1800 51 21 21 between 8:30am-5:00pm, Monday to Friday
After-hours: 1300 363 746
Website: Melbourne Carer Services | Alfred Health Carer Support Service
Referral: Make A Referral
Carer Gateway and Emergency Respite
Referral Form: Carer Gateway Referral Form
Phone: Carer Gateway on 1800 422 737 between 8:00am-5:00pm, Monday to Friday
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Community Rehabilitation Program
Located within the Alfred Health Falls Clinic
Service Address: Ashley Ricketson Centre (Building 22) – enter through Gate 2
Caulfield Hospital, 260 Kooyong Road, Caulfield, 3162 VIC
Email: gcgmcaccess@alfred.org.au
Website: Community Rehabilitation Program | Alfred Health
Phone: (03) 9076 6207
Fax: (03) 9076 6773
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Advanced Care Planning
Phone: (03) 9076 6642
Email enquiries: advancecareplanning@alfred.org.au
Website: Alfred Health Advanced Care Planning
Monash Health Aged Care Referral Pathways
Referrals for the following Monash Health services can be sent through Healthlink. Monash Health resources for Healthlink can be found here - Healthlink referrals for GPs
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Falls and Balance Clinic
Service Address: Movement Disorders Clinic Building, Specialist Clinics Consulting Suites
Warrigal Road, Cheltenham 3192
Email: icareaccess@monashhealth.org
Website: Falls and Balance Clinic
Falls Clinic Phone: 03 9265 1411
Referral Enquiries: 03 8572 5631
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Chronic Disease Services (HARP Complex Care)
Service Addresses: Various locations across the Monash Community Health Services locations including:
• Cranbourne
• Pakenham
• Berwick
• Doveton
• Dandenong
• Springvale
Email: icareaccess@monashhealth.org
Website: Chronic and Complex Care program
Phone: 03 8572 5631
Clinics run weekdays 9 am to 5:30 pm
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Hospital in the Home
Home-based service
Referral Type: To contact Hospital In The Home for a referral, call the switchboard at the appropriate hospital site and ask for the HITH doctor or HITH Coordinator. Referrals are by phone seven days per week.
Email: icareaccess@monashhealth.org
Website: Hospital in the Home | Monash Health
Phone: (03) 9594 6666
The team is made up of medical and nursing staff. Nurse visits occur between 7am to 9pm and are available by phone 24 hours a day. Medical supports are available from 8am to 10pm
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The Cognitive Dementia and Memory Service (CDAMS)
Service Address:
The Kingston Centre,
400 Warrigal Road,
Cheltenham, Vic 3192
Referral Email: icareaccess@monashhealth.org
Website: Monash Health CDAMS website
Phone: 03 8572 5631
CDAMS Clinic: 03 9265 1411
Fax: 03 9265 1297
Service Enquiries Email: sacs.specialistclinics@monashhealth.org
Clinics: Mondays, Tuesdays, Wednesdays and alternate Thursdays (excluding public holidays) between 9am-5pm. Bookings are required.
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Aged Mental Health
This service is home-based.
Email: icareaccess@monashhealth.org
Website: Aged Mental Health
Referral Phone: 03 8572 5631
Kingston Centre Phone: (03) 9265 1750
Endeavour Hills Centre Phone: (03) 9709 7107
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Carer Support (Community Support Options Respite Care)
Service Address: Level 1,55 Buckingham Avenue Springvale VIC 3171
Community Support Options Respite Care is available for carers who live in these areas:
- Casey, Cardinia, Greater Dandenong
Email: communitysupportoptions@monashhealth.org
Website: Respite care – Community Support Options
Community Support Options Phone: (03) 9792 7747
Referral Phone: 1800 200 422
Referral Fax: 1800 725 174
Carer Gateway and Emergency Respite
Referral Form: Carer Gateway Referral Form
Phone: Carer Gateway on 1800 422 737 between 8:00am-5:00pm, Monday to Friday
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Monash Health Community
Service Address: Various locations across the Monash Community Health Services locations including:
Cranbourne, Pakenham, Berwick, Doveton, Dandenong, Springvale, In the home
Email: icareaccess@monashhealth.org
Website: Community Health / Monash Health Community
Referral Phone: 03 8572 5631
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Monash Health Occupational Therapy Driver Program
Referral information:
Under 65: Referrals should be sent by eReferral through Healthlink or by email.
Over 65: Referrals must be made through My Aged Care Portal - Make a Referral
Email: otdrivingservice@monashhealth.org
Website: Occupational Therapy Driver Program | Monash Health
Referral Phone: 03 8572 5631
Fax: 03 9265 1836
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Monash Health Dietetics
Referral information:
Under 65: Referrals should be sent by eReferral through Healthlink or by email.
Over 65: Referrals must be made through My Aged Care Portal - Make a Referral
Email: icareaccess@monashhealth.org
Website: Dietetics – Community Health | Monash Health
Referral Phone: 03 8572 5631
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Community Rehabilitation
Service Locations:
• Cranbourne
• Dandenong
• Kingston
• Pakenham
• Springvale
• Home-based
Email: icareaccess@monashhealth.org
Website: Community Rehabilitation (Home and Centre based) | Monash Health
Referral Phone: 03 8572 5631
Intake Phone: 1300 342 273
Opening Hours:
8 am to 4:30 pm Monday to Friday
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Advanced Care Planning
Referral to Advance Care Planning
Email: acp@monashhealth.org
Phone: (03) 9594 3475
Website: Monash Health Advanced Care Planning
Peninsula Health Aged Care Referral Pathways
Please contact the GP Liaison Unit for further information for any clinics and services listed below:
Danielle Rule (RN/Midwife/MCHN)
GP Liaison Unit Project Officer
(Mondays & Tuesdays 8.30am-4.30pm)
Dr Joanne Newton
GP Liaison Consultant
(Tuesdays & Wednesdays 9.30am -2pm)
Enquiries
Appointments and General Enquiries (03) 9784 2600
Patient enquiries via Outpatients (03) 9784 2600 or ACCESS on 1300 665 781
Clinical or Urgent Outpatient Referral Enquiries:
(8:30 am to 5:00 pm Mon to Fri)
(03) 9784 7155
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Falls Prevention Clinic
Service Address:
The Mornington Centre, Cnr Tyalla Grove & Separation Street, Mornington Vic 3931
Website: Falls Prevention - Peninsula Health
Phone: (03) 5976 9011
Referral Phone: 1300 665 781
Referral Fax: (03) 9784 2322
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Peninsula Health At Home
Website: At Home - Peninsula Health
Referral Phone: 1300 665 781
Referral Fax: (03) 9784 2322
Service Addresses:
Frankston Community Health
Frankston Integrated Health Centre
2 Hastings Road Frankston 3199
Fax: 03 9784 8149
Website: Frankston Community Health - Peninsula Health
Phone: 03 9784 8100
Hastings Community Health
185 High Street Hastings 3915
Fax: 03 5971 9106
Website: Hastings Community Health - Peninsula Health
Phone: 03 5971 9100
Mornington Community Health
62 Tanti Avenue Mornington 3931
Fax: 03 5975 8257
Website: Mornington Community Health - Peninsula Health
Phone: 03 5970 2000
Rosebud Community Health
1527 Point Nepean Road Rosebud West 3940
Fax: 03 9784 2321
Website: Rosebud Community Health - Peninsula Health
Phone: 03 5986 9250
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Community Care
Services are provided in the home and at various locations across the Frankston, Hastings, Mornington, and Rosebud Community Health sites.
Email: CommunityCareEnquiry@phcn.vic.gov.au
Website: Community Health Services - Peninsula Health
Referral Phone: 1300 665 781
Referral Fax: (03) 9784 2322
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Cognitive Dementia and Memory Service (CDAMS)
Service Address:
The Mornington Centre
Cnr Tyalla Grove & Separation Street
Mornington Vic 3931
Website: Cognitive, Dementia and Memory Service
Service Phone: (03) 5976 9012
Referral Phone: 1300 665 781
Referral Fax: (03) 9784 2322
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Community Stroke Rehabilitation
Service Address:
Golf Links Road Rehabilitation Centre
125 Golf Links Rd, Frankston VIC 3199
Website: Golf Links Road Rehabilitation Centre - Peninsula Health
Service Phone: (03) 9784 8799
Referral Phone: 1300 665 781
Referral Fax: (03) 9784 2322
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Hospital Admission Risk Program (HARP)
Service Address:
Home-based, clinicians based at various locations across the Frankston, Hastings and Rosebud Community Health sites.
Website: Hospital Admission Risk Program (HARP) - Peninsula Health
Service Phone: (03) 9788 1700
Referral Fax: (03) 9788 1206
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Elder Abuse: Support for older people
Website: Elder Abuse support and resources
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Aged Mental Health
Website: Aged Persons Community Mental Health Program (APCMHP)
Service Phone: 1300 792 977
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Carer Support Program
Website: Carer Support Program
Service Phone: 1300 665 781
Referral Fax: 03 9784 2309
Call between 8:30am-5:00pm (Monday-Friday) and an Access Worker will give you further details on the service.
Carer Gateway and Emergency Respite
Referral Form: Carer Gateway Referral Form
Phone: Call Carer Gateway on 1800 422 737 between 8:00am-5:00pm, Monday to Friday
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Nutrition and Dietetics
Website: Nutrition and Dietetics
Referral Phone: 1300 665 781
Referral Fax: 03 9784 2309
Service Phone: (03) 9784 2660
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Advanced Care Planning
Advance Care Planning Service
Phone ACCESS: 1300 665 781
Email: acp@phcn.vic.gov.au
Website: Peninsula Health Advanced Care Planning
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