Care Coordination and Supplementary Services

Our Care Coordination and Supplementary Services (CCSS) Program is a service for local Aboriginal and Torres Strait Islander people with respiratory disease, renal disease, cardiovascular disease, diabetes or cancer.

  1. Care Coordination: provided by appropriately qualified and trained clinical staff to Aboriginal and Torres Strait Islander patients with a chronic disease. Clients of the service should be referred in by their GP.
  2. Supplementary Services: A flexible pool of funds that can be used to assist clients receiving care coordination under the CCSS program. The funds can be used to improve access to medical specialist and allied health services that are in accordance with the client's care plan.

Care Coordinators are qualified health workers (for example, nurses, allied health professionals or Aboriginal Health Workers) who support eligible patients to access the services they need to treat their chronic disease according to the General Practitioner (GP) care plan.

The work of a Care Coordinator can include providing clinical care, arranging the services in patients’ care plans and assisting patients to participate in regular reviews by their primary care providers. Care Coordinators work closely with Aboriginal Outreach Workers in many of these activities.

Our Care Coordination and Supplementary Services (CCSS) Program is a service under the ITC program for local Aboriginal and Torres Strait Islander people with; respiratory disease, renal disease, cardiovascular disease, diabetes or cancer.

Care coordinators who will work collaboratively with GPs in accordance with the client’s care 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 Pool can also be used to assist patients to access some GP approved medical aids.

From 1 April 2017, outreach services will be provided by South Eastern Sydney Local Health District and Sydney Local Health District.

All services provided by the Care Coordinator are FREE.

If you are a GP with an Aboriginal or Torres Strait Islander patient who could benefit from the above services please complete the   pdf CCSS Referral Form (352 KB)  and send it via secure fax to 9009 0690.

For further information on the service please download the Care Coordination brochure.

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