Our Care Coordination and Supplementary Services Program

Contributing to improved health outcomes for Aboriginal and Torres Strait Islander people with chronic health conditions.

Hunter Primary Care has been funded by Department of Health to provide a Care Coordination and Supplementary Services (CCSS) Program for Aboriginal people who live in the Newcastle and Hunter area. There is no cost to patients for this program.

The service is based in Hunter Primary Care’s Newcastle and Maitland offices along with our Closing the Gap team. Referrals are received from GPs who believe their patients will benefit from increased support around their chronic disease management. The CCSS Program will offer services that are patient focused, confidential, culturally appropriate and sustainable.

Frequently asked questions about Care Coordination and Supplementary Services

To be eligible Aboriginal and Torres Strait Islander patients must:

  • Be referred by their general practitioner
  • Have a current GP Management Plan and/or Team Care Arrangement; and
  • Be identified by their GP as having one of the following chronic diseases:
    • Diabetes;
    • Cardiovascular disease;
    • Chronic renal disease;
    • Chronic respiratory disease;
    • Cancer; and
    • Mental health conditions

Not all patients with a chronic condition will need assistance through the CCSS Program. When referring patients, GPs should give priority to patients most in need of care coordination services to obtain improved health outcomes. As a guide, patients most likely to benefit from the CCSS Program include:

  • Patients who are at greatest risk of experiencing otherwise avoidable (lengthy and/or frequent) hospital admissions;
  • Patients at risk of inappropriate use of services, such as hospital emergency presentations;
  • Patients not using community based services appropriately or at all;
  • Patients who need help to overcome barriers to access services;
  • Patients who require more intensive care coordination than is currently able to be provided by general practice, Indigenous health services, and/or Local Health District (community health) staff; and
  • Patients who are unable to manage a mix of multiple community based services.
The CCSS Program has two components:

  • Care Coordination – is provided by a Care Coordinator who support Aboriginal and Torres Strait Islander patients by arranging the health services identified in a GP Management Plan or Team Care Arrangement by;
    • Ensuring there are arrangements in place for the patient to get to appointments;
    • Assisting the patient to participate in regular reviews by their primary care provider/s;
    • Supporting a patient’s adherence to treatment regimes (eg. medication compliance);
    • Supporting and encouraging the patient and the family to develop chronic condition self-management skills; and
    • Linking the patient and family with appropriate community based services such as those providing support for daily living.
  • Supplementary Services – a pool of funds available to assist patients receiving care coordination under the CCSS Program, in accordance with their GP Care Plan. The funds can be used to access private medical specialists and allied health services where a delay in public services would be considered clinically inappropriate. Transport to and from these appointments can also be provided if alternative transport is unavailable. Some medical aids required to manage the client’s (eligible) chronic disease/s can also be funded.
Hunter Primary Care employs a team of Aboriginal and Torres Strait Islander Outreach Workers (AOW) to help Aboriginal and/or Torres Strait Islander people access health care and follow-up services. The AOW will provide assistance and support to the Care Coordinator and participating GP practices.
For further information phone (02) 4935 3230.
The GP referral form for the CCSS Program can be found on the HealthPathways website. Templates are available for Best Practice, Medical Director, as well as a pdf.

Alternatively you can download the following forms:

A completed and signed referral, along with a copy of a current GP Management Plan can be sent to HPC at carecoordintake@hunterprimarycare.com.au or via fax at (02) 4925 2268.

For further information or for assistance accessing HealthPathways please phone (02) 4935 3230.

Read about about our CCSS Program in this attached brochure.

To receive additional information or to refer an eligible patient to the Care Coordination and Supplementary Service Program contact Claudine Ford on (02) 4925 2259 or 0437 370 151.