Health and Wellbeing Project

 Program Officer
Lisa Merrison - 9330 9947 | l.merrison@cesphn.com.au

What is the Health and Wellbeing Project and who can use it?

The Health and Wellbeing project provides support to primary health care providers to provide culturally appropriate primary health care services to Aboriginal and Torres Strait Islander people by offering a suite of practice support services and through an Integrated Team Care (ITC) program for patients which aims to;

  • contribute to improving health outcomes for Aboriginal and Torres Strait Islander people with chronic health conditions through better access to coordinated and multidisciplinary care; and
  • contribute to closing the gap in life expectancy by improved access to culturally appropriate mainstream primary care services (including but not limited to general practice, allied health and specialists) for Aboriginal and Torres Strait Islander people.

The objectives are to:

  • achieve better treatment and management of chronic conditions for Aboriginal and Torres Strait Islander people, through better access to the required services and better care coordination and provision of supplementary services;
  • foster collaboration and support between the mainstream primary care and the Aboriginal and Torres Strait Islander health sectors;
  • improve the capacity of mainstream primary care services to deliver culturally appropriate services to Aboriginal and Torres Strait Islander people;
  • increase the uptake of Aboriginal and Torres Strait Islander specific Medicare Benefits Schedule (MBS) items, including Health Assessments for Aboriginal and Torres Strait Islander people and follow up items; support mainstream primary care services to encourage Aboriginal and Torres Strait Islander people to self-identify; and
  • increase awareness and understanding of measures relevant to mainstream primary care.
Services offered to patients

The services offered to patients are:

Care Coordination is a clinical service under the ITC program for local Aboriginal and Torres Strait Islander people with chronic disease e.g. respiratory disease, renal disease, cardiovascular disease, diabetes or cancer.

Care coordinators who will work collaboratively with GPs in accordance with the client’s GP Management Plan. The care coordinators may assist clients in a number of ways:

  • Assist people in understanding their chronic health condition and help them to develop self-management skills
  • Assist with understanding of medicines
  • Assist with lifestyle changes and referrals to programs to assist
  • Facilitate connections to other community support services
  • Organise appointments and/or transport with appropriate services; and
  • Advise on the importance of following care plans, for example assisting patients to participate in regular reviews with their GP or recommended follow up appointments with allied health or specialists.

Care Coordinators have access to a Supplementary Services funding pool when they need to expedite a patient’s access to an urgent and essential allied health or specialist service, or necessary transport to access the service, where this is not publicly available in a clinically acceptable timeframe.

The Supplementary Services funding can also be used to assist patients to access some GP approved medical aids.

Outreach Workers are a component of the Integrated Team Care (ITC) program to encourage Aboriginal and Torres Strait Islander people to access health services and help to ensure that services are culturally appropriate. They have strong links to the community they work in.

The Aboriginal Outreach Worker provides non-clinical services including the following:

  • Information and resources about locally available health services
  • Referrals to culturally appropriate health care providers and services
  • Information and assistance with travel options to and from health appointments
  • Support when attending health appointments, including GPs, specialists, allied health providers and diagnostic tests
  • Assistance with effective communication between yourself and the health care provider
  • Information about local community services and activities

 

Eligibility

 

To be eligible to access the ITC program, clients need to:

  1. Identify as being Aboriginal or Torres Strait Islander
  2. Have a referral for access to the ITC program (patients requiring clinical support with a chronic disease require a GP Management Plan)
  3. Provide written consent

All services provided are strictly confidential and free.

 

How to access this service

 

Generic CESPHN referral forms are available here:

Please see under provider for links to specific service referral forms.

Provider

 

Sydney Local Health District Intake
Access Care Team [ACT] Telephone: 1300 722 276 
Fax 97677026 
Email -SLHD-ACTCallCentre@health.nsw.gov.au

Link for electronically submitted referral -
https://www.slhd.nsw.gov.au/ACRS/form/RIC_Referral_Form.pdf

South Eastern Sydney Local Health District Intake 
South Eastern Aboriginal Health Care Telephone 02 9540 8181
SEAHC Fax: 02 9540 8165 
Email : seslhd-seahc@health.nsw.gov.au

 

 

 

Generic CESPHN referral forms are available here:

Care Coordination
Outreach Workers

Please see under provider for links to specific service referral forms.

 

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