General Practitioners and Social Workers in Sydney’s northern suburbs are collaborating to improve people’s daily lives through an innovative and free program. Nothing illustrates the results of this collaboration more than Northern Sydney resident, Teresa Caruso’s turnaround. Teresa, a 62-year-old mother of two and grandmother of three, couldn’t get off her couch. Outside her home, the local community was largely unaware of Teresa’s difficulties.
Teresa’s health condition had deteriorated over time. Her physical and mental health complications resulted in days increasingly spent at home in the living room, watching television, with limited sunshine and social interaction except with her immediate family. Frank, Teresa’s husband of almost 40 years, had become her full-time carer. “Frank does all the cooking and cleaning. He’s a very good man,” says Teresa.
As Teresa’s health declined, she decided to reach out to her General Practitioner (GP). Besides attending to Teresa’s immediate medical needs, the GP recommended a more integrated approach to Teresa’s care, referring her to the “GP Social Work Connect Program”. In Teresa’s case the organisation delivering this program is Primary & Community Care Services (PCCS), a not-for-profit local health organisation. The need for this program was identified and commissioned by the Sydney North Primary Health Network on behalf of the Australian Government.
Sarah Melvin from PCCS was appointed Teresa’s social worker. “Working in partnership with Teresa’s GP, I am here to help Teresa and her family navigate the complex social services sector – helping her to be more independent and socially active. Working with her GP, I am addressing psycho-social  issues, helping to resolve these with personalised support, and helping Teresa access complimentary services in the local community and beyond.”
“When I first came to meet Teresa, she told me she never left the house. So, one of my suggestions was to help her access community, social and group activities. Originally Teresa was resisted the idea, but after six weeks of working together, I now receive phone calls from Teresa about what groups and activities she can attend. Teresa is much more confident, social, and wanting to get out and about and try new things,” Sarah said.
“The idea of the GP Social Work Connect program is for the GP to focus on the health and medical needs of the patient, and refer to the social workers to assist with social services needs. These may include the National Disability Insurance Scheme (NDIS), My Aged Care, Centrelink, Department of Housing, community transport, helping people who have become dependent on drugs or alcohol or even supporting carers suffering from stress and burnout. It’s coordinated care in action,” says Cynthia Stanton – General Manager, Primary Care Advancement and Integration, Sydney North Primary Health Network.
Teresa now has a team around her with specialist skills for her coordinated care and to ensure she lives a fuller and healthier life. “I feel more alive, I feel better with myself, and when I go out it’s beautiful, and Sarah did that for me. Thanks to Sarah I now have my Disability Support Pension and Frank (Teresa’s husband), and I go out every morning now - walking, shopping, watching people pass by, and drinking cappuccinos. With the social groups, I have been around looking at Christmas lights, had dinners at the Club, and seen the Harbour. I want to continue with the social groups,” says an excited Teresa.
From a GP’s point of view, this service has taken the burden away from GPs having to deliver both medical and social services care. Dr Caroline Rogers, GP and Medical Director of Warringah Medical and Dental Centre, says, “Some of my patients who are trying to access complex social services are at vulnerable, ageing, or declining points in their lives. The social workers through the GP Social Work Connect program help my patients as advocates, navigating systems, lodging appeals, and helping those who sometimes fall through the gaps. They are amazing!”
“When I find a patient that is not accessing the care that they need or when there is a complicated situation that is really when the social worker service comes into its own. Patients think this is a wonderful service and are very appreciative of the extra help. The social workers are wonderful communicators, educators, negotiators, researchers and great at breaking down barriers. They can help re-establishing routines, stability, and access to services and social connection. Their knowledge about available social services means I can focus on the health and medical care of the patient and identifying and gaps and needs.”
At the end of 2017, 195 General Practitioners referred 304 patients to participate in the program.
Photography Credit: Bec Lewis