Referring to our Aboriginal Health and Wellbeing Services
Care Coordination and Supplementary Services
At Hunter Primary Care, we aim to contribute to improving health outcomes for Aboriginal and Torres Strait Islander people with long term health conditions by providing better access to coordinated and multidisciplinary care. We also aim to improve the gap in the life expectancy of Aboriginal and Torres Strait Islander people by improving access to culturally appropriate mainstream primary care services, including but not limited to, general practice, allied health and specialists.
To be referred to our Care Coordination and Supplementary Services (CCSS) a GP must first complete the referral form below and provide the following documentation at the time of referral :
1 - a) A current GP Management Plan and/or Team Care Arrangement; b) and/or Mental Health Care Plan,
2 - A current 715 Health assessment
3 - Have one of the following chronic diseases requiring complex care coordination:
- cardiovascular disease;
- chronic renal disease;
- chronic respiratory disease;
- mental health conditions
Please note, not all patients with the eligible chronic conditions will require assistance through this service. Priority will be given to people who have complex chronic care needs, and require intense multidisciplinary coordinated care for their chronic disease than that being currently provided by general practice and/or AMS staff.
As a guide, patients most likely to benefit from the CCSS Program include patients:
- at greatest risk of experiencing otherwise avoidable (lengthy and/or frequent) hospital admissions;
- at risk of inappropriate use of services, such as hospital emergency presentations;not using community-based services and or funding appropriately or at all;
- who need help to overcome barriers to access services;
- who are unable to manage a mix of multiple community-based services.
A completed and signed referral, along with a copy of current plans as mentioned above can be sent to the Hunter Primary Care care coordinator intake team by email to firstname.lastname@example.org or via fax at (02) 4925 2268.