General Practice SUSTAIN Trial
Expression of Interest Application Form
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This EOI Application Form will take ~ 10-15 minutes to complete. Specific requested information includes paediatric patient numbers and reasons your practice wishes to participate in the trial.
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Please complete your general practice details
Name of General Practice
ABN
Address
Suburb
Postcode
Project Lead Contact Person
Email address
Phone
Your General Practice
Is your practice accredited or working towards accreditation?
Yes
No
Working towards
Accreditation/Re-accreditation date
Do you have Best Practice or Medical Director software?
(NB Only practices who have BP or MD are eligible to participate due to compatibility with research data extraction tool GRHANITE)
Yes
No
Software and version
If your practice utilises Medical Director, are you intending to migrate to the cloud-based version (Helix) prior to October 2023? (If yes, we will contact you to discuss further)
Yes
No
Able to provide protected time for staff/clinicians to participate in trial activities. This includes co-consults and attend monthly case discussions
Yes
No
Able to manage bookings and reminders for Paediatrican appointments at general practice
Yes
No
Willing to install audit and data collection software? (GRHANITE)
Yes
No
Detail any further information required
Able to complete all evaluation and research requirements including monthly data submission ? (automatically via EMR with GRHANITE)
Yes
No
Able to provide protected time and support for all clinicians to record coded diagnosis and referral activities for all patients 0-18 years in their existing EMR
Yes
No
Participating GPs agree to enrol in the Sydney Child Health Program FREE of charge
Yes
No
Detail any further information required
What are your billing practices for general consultations with patients <18 years of age?
How many GPs work in your practice?
Do you consent to be contacted by the SUSTAIN Project Team to hear more about this trial study?
Yes
No
If yes, tell us the best person to contact
Email
Detailed Project Description
What is the number of patients aged 0-18 years seen in your practice during 2021-2022?
(Please use PENCAT or POLAR to extract details)
Why does your practice wish to be involved in this trial study?
(~ 200 words)
How will your
patients benefit
from participation in this project ? (
~100 words)
How will your
practice benefit
from participation in this project ?
(~100 words)
Please outline how you will support trial activities being implemented in your general practice?
(~200 words)
Any further questions or comments?
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