care coordination and supplementary services (ccss)



care coordination and supplementary services (ccss)
The Aboriginal Chronic Disease Package
aims to contribute to closing the gap in life
expectancy for Aboriginal and Torres Strait
Islander people by improving culturally
sensitive primary care services.
Mainstream primary care provides a first
point of call for health services in Australia.
However, cultural barriers can limit usage
of these services. Increasing the
capacity of mainstream primary
care to provide culturally
sensitive services for
Aboriginal and Torres
Strait Islander people
will increase the options
available and ultimately
improve health and wellbeing.
The CCSS Program aims to help you:
We acknowledge the traditional land owners past
and present on whose land we work and live.
For more information about the Care Coordination
and Supplementary Services Program please call:
02 4220 7688
02 4448 2203
• improve overall health and
wellbeing of Aboriginal and Torres Strait
Islander clients
Suite 1, 336 Keira St Wollongong
(entrance on West St) NSW 2500
PO Box 1198 Wollongong NSW 2500
t: 02 4220 7688 f: 02 4226 6489
• improve access to culturally
sensitive primary care services
for Aboriginal and Torres Strait Islander
107 Scenic Drive Nowra NSW 2541
PO Box 516 Nowra NSW 2541
t: 02 4448 2203 f: 02 4423 6451
• improve management of chronic
conditions of Aboriginal and Torres Strait
Islander clients and their family/carers.
Grand Pacific Health Ltd. ABN 49 062 587 071 acknowledges support received from the
Australian Government Department of Health
Information for Health Professionals
What is the CCSS Program?
The program aims to support better access to
specialist, GP and allied health services for Aboriginal
and Torres Strait Islander people identified as needing
more complex chronic disease management.
Who is eligible for the CCSS Program?
To be eligible for care coordination under the program,
Aboriginal and Torres Strait Islander clients must:
• be registered with Medicare
• have a current GP Management Plan and/or
Team Care Arrangement
• be recommended (written referral) by their GP
• have been diagnosed with one or more of the
targeted chronic diseases - cardiovascular
disease, respiratory disease, renal disease,
cancer, diabetes.
How to access the CCSS Program
1. GP obtains client written consent to participate in
CCSS program.
2. Written GP Referral to CCSS.
3. Fax referral, client consent and copy of CARE
PLAN to:
f: 02 4423 6451 Attention: CCSS team
f: 02 4226 6489 Attention: CCSS team
4. Care Coordinator will then contact the client and
discuss/arrange appointment.
5. Care Coordinator communicates with general
practicioner (GP) re service coordination/
supplementary service provided to client as well as
update care plan etc.
6. For GP referral and client consent forms visit
Who will benefit from the Care
Coordination Program?
Aboriginal and Torres Strait Islander clients who:
• are at greatest risk of experiencing otherwise
avoidable (lengthy and/or frequent) hospital
admissions because of their chronic conditions
• are at risk of inappropriate use of services, such
as hospital emergency presentations
• are not using community based services
appropriately or at all
• need help to overcome barriers to access
• require more intensive care coordination
• are unable to manage the mix of multiple
community based services.
How the Care Coordinator can help
The Care Coordinator is a nurse or other health
worker who can:
• arrange appointments (specialist, allied health,
exercise physiologist)
• arrange community transport/private taxi
• arrange domestic assistance/respite/financial
• help clients follow their care plan (medication
and compliance education).
There is no cost to
access the program.
Duties of a care coordinator
• Work closely with clients, carers and primary
care teams regarding coordination and
continuity of care.
• Work collaboratively with mainstream and
Aboriginal health services to implement effective
care service linkages.
• Support, educate and build capacity to deliver
improved care planning, chronic disease
management and continuity of care;
• Link clients with culturally appropriate primary,
specialist and allied health services.
• Work closely with Aboriginal Community
Support Worker to arrange practical support
for clients to access appointments, transport
• Assist clients to develop understanding of their
chronic condition and day to day management.
• Administer allocation of the Supplementary
Services Funding as per guidelines.
• Participate in clinical meetings, organisation wide
team meetings, collaborative planning activities
and quality assurance activities.

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