Chronic Disease Care Coordination


What is the Care Coordination Supplementary Services Program (CCSS)?


The Program aims to support better access to Specialists, 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?


To be eligible for care coordination under the program, Aboriginal and Torres Strait Islander clients must:
    * have a Medicare card;
    * have a current Management Plan and/or 715 Health Check;
    * have a referral from your GP or Health Worker;
    * have diagnosed chronic diseases — cardiovascular, respiratory, renal, cancer, diabetes or mental health. 

Who will benefit from CCSS?


Aboriginal and Torres Strait Islander clients who:
are at risk of hospital admission because of their chronic conditions;
are not using community based services;
need help to access services;
require more intensive care coordination.

How the Care Coordinator can help you!

The Care Coordinator is and Aboriginal Health Worker who can:
arrange appointments with Specialist and Allied Health Professionals;
arrange transport, taxi and/or fuel cards;
assist you to follow your care plan, medication etc.

Outreach Worker Program


The Outreach Worker program is for all Aboriginal and Torres Strait Islander People requiring assistance to attend Medical Appointments.

Am I eligible for CCSS?


Am I Aboriginal and/or Torres  Strait Islander?

Do I have one or more of these diseases (diabetes, heart respiratory, kidney, cancer, mental health)?

Do I have a current Management Plan or 715 Health Check?


If you answer YES to the above questions, or think you are eligible please speak with one of the Goondir health team.

For further information on eligibility and how to access the ITC Care Coordination & Supplementary Services and
Outreach Worker Program please contact:

Jess Bartholomew
Client Support Coordinator
0436 679 038

The ITC program is funded by the Department of Health, contracted to Goondir Health Services for service delivery in the Dalby Region of the Darling Downs West Moreton Primary Health Network (PHN) area.