SOUTH WESTERN MELBOURNE

Care Coordination and Supplementary Services program (CCSS)

The main role of the CCSS Program is to improve chronic disease prevention and management for local Aboriginal and Torres Strait Islander’s by enabling better access to allied health and specialist services.

The CCSS Care Coordinator will work to identify barriers restricting access to services, provide information about the services available within the region, encourage and support patients to access related health services as identified on their care plan, and assist patients to attend appointments and access recommended care.

Patients in the CCSS program may access supplementary services funding, which can be used flexibly when there is a barrier to care, such as a lack of available appointments with a publicly funded providor to access to affordable local transport to attend appointments.

Supplementary services funding is limited and should be used when responding to urgent needs.

Please contact Alex Rojas for more information [email protected]  or call 8731 6540 

Patient eligibility

To be eligible for the Care Coordination and Supplementary Services program patients must:

  • have a care plan
  • be enrolled for chronic disease management in a general practice
  • be recommended by their GP

 and have one of the following chronic diseases:

  • diabetes
  • cardiovascular disease
  • respiratory conditions
  • renal disease
  • cancers

Patients most likely to benefit are

  • patients who are at a great risk of experiencing otherwise avoidable lengthy and/or frequent hospital admissions
  • patients at risk of inappropriate use of services, e.g. hospital emergency presentations
  • patients not using community based services appropriately
  • patients who need help to overcome barriers to access services
  • patients who require more intensive care coordination than is able to be provided by General Practice or Indigenous Health Service staff
  • patients who are unable to manage a mix of multiple community based services

For the GP referral form, click here

For the Pharmacist referral form, click here

Fact Sheet 
Program Guidelines
The CCSS program is part of the Closing the Gap funding