Appendix 5: ARF / RHD jurisdictional specific issues

​ARF is not currently notifiable in ACT, Victoria or Tasmania.

Cross jurisdictional/border issues: Control programs or treating clinicians should ensure that for patients transferred from one jurisdiction to another, all relevant details, especially benzathine penicillin dosing dates, are provided. No formal transfer of care form is currently in use.  This process is guided by the CDNA Cross-border NNDSS Notification Protocol.

There is no National register. For information on RHD programs and notification process in each jurisdiction visit: RHDAustralia.

NSW case management roles and responsibilities

Primary health care providers and hospitals

1. Investigate and diagnose new cases of ARF and RHD.
2. Notify all new and recurrent cases of ARF and RHD aged <35 years to the local PHU.
3. Obtain consent to enrol patients with newly diagnosed ARF or RHD onto the RHD Register.
4. Provide ongoing clinical management for patients with ARF and RHD including providing secondary prophylaxis.

LHD RHD Coordinator

1. Coordinate discharge planning with hospital staff when clients are in-patients and ensure information about follow-up appointments is sent to the NSW RHD Coordinator.
2. Identify an appropriate case manager for each case.
3. Work with clinical networks on active case finding, including active surveillance.
4. Inform the NSW RHD Coordinator when patients complete the treatment period, move between LHDs or interstate, or wish to leave the register.
5. Work with the treating doctor and case manager to consent cases to the register.
6. Assist the case manager with strategies to retain patients in care when cases have missed appointment or are lost to follow-up.

Case Manager

1. Liaise between patients and primary care providers to facilitate monthly penicillin injections and specialist appointments, or liaise with the patient directly if the case manager is also the primary care provider.
2. Provide feedback on adherence to monthly prophylaxis and follow-up appointments to the register in response to reminders by the NSW RHD Coordinator.
3. Alert the LHD Coordinator of patients who are lost to follow-up, moving between LHDs/interstate or wishing to leave the register.

NSW RHD Coordinator

1. Send monthly reminders of penicillin injections to case managers.
2. Receive responses from case managers on follow-up appointments and enter them onto the Register.
3. Liaise with the LHD Coordinator regarding patients who are lost to follow-up or not accessing care.
4. Remove patients from Register if requested to do so.
5. Support public health units in case classification.
6. Coordinate active surveillance for people newly diagnosed with ARF and RHD