Care Coordination
In recognition of the significant overlap and interaction between health outcomes and the key social and economic determinants of health and behavioural risk factors, IUIH aims to strengthen efforts to help Aboriginal and Torres Strait Islander families connect with social support services through integrating and coordinating care.
IUIH has continued to improve services through a ‘no wrong door’ environment, integrating health and social support services centred on Aboriginal and Torres Strait Islander patients using the health system.
Integrated Team Care (Care Coordination and Supplementary Services)
The Integrated Team Care program includes the Improving Indigenous Access to Mainstream Primary Care and Care Coordination and Supplementary Services programs.
The Improving Indigenous Access to Mainstream Primary Care program provides engagement and education support to mainstream practices within the region including delivering cultural awareness training to enhance the cultural safety of Aboriginal and Torres Strait Islander people attending mainstream primary healthcare services.
The Care Coordination and Supplementary Services program aims to provide better access to coordinated and multidisciplinary care for Aboriginal and Torres Strait Islander people who have chronic conditions including:
- Access to specialists, allied health services and other support services
- Access to specified medical aids that are needed to manage clients conditions effectively
- Provision of appropriate clinical care
- Arranging services
- Assisting patients to attend appointments
- Ensuring medical records are complete and current
- Ensuring regular reviews are undertaken by the patient’s health care team.
Referrals
General Practitioner Referral Form for Care Coordination and Supplementary Services (CCSS)
IUIH Pharmacy Support Service
IUIH’s Pharmacy team focuses on monitoring and continually improving the quality and safety of medicine use across the region through providing extended support for community, working closely with other IUIH programs and externally with community pharmacies and hospital pharmacists.
The IUIH Pharmacy team also provides education and clinical support for IUIH member services and their patients including:
- Providing training and development of the IUIH Network workforce in the safe and effective use of medicines
- Coordinating, tracking and ensuring follow up of Home Medicine Reviews.
- Supporting systems for effective monitoring and implementation of clinic imprest and vaccine stock.
- Reviewing medication use as part of local clinic teams.
General informationGeneral information
Care Coordination Supplementary Services (CCSS) provides a culturally safe service for Aboriginal and Torres Strait Islander people with chronic health conditions. The team walks alongside our clients to access services, manage symptoms, and empower Mob to make deadly choices about wellbeing and care.
Our team can support Mob with:
- accessing appropriate clinical care
- attending appointments
- arranging services such as allied health
- ensuring medical records are complete and current
- ensuring regular reviews are undertaken by the healthcare team
- assisting clients to understand their chronic health condition and how to best manage it
- reminding clients to attend regular review appointments with their GP and other health-related appointments
- providing support to identify signs that a condition may need further management.
LocationsLocations
CCSS is available to Mob in South East Queensland.
The program is also available nationwide via the Australian Government, Department of Health and Aged Care.
ReferralsReferrals
Who to refer
CCSS is free for Aboriginal and Torres Strait Islander clients of all ages who:
- have a chronic disease
- are enrolled for chronic disease management in a mainstream general practice or Aboriginal Medical Service/ACCHO, and
- have a care plan.
How to refer
External
Provide:
- A signed Care Coordination Supplementary Service consent/referral form
- General Practice management plan and team care arrangements (MBS 721 and 723).
- Indigenous Health Assessment (MBS 715), with allied health follow up.
IUIH network
MMEx:
- Open Patient Record
- Click on Referrals/Visits Tab
- Create New Referral
- Create a referral letter from a template > Search ‘CCSS ITC’ > Select ‘CCSS staff member’
- Press Send as Message
Contact
Mob Link, 1800 254 354 | [email protected]
Client informationClient information
Mob Link CCSS Brochure
Please download the Mob Link Care Coordination Supplementary Services (CCSS) client brochure to share with your patients.
Download
