GP FACT SHEET
CARE COORDINATION AND SUPPLEMENTARY SERVICES
& ABORIGINAL OUTREACH WORKER PROGRAMS
for Aboriginal and Torres Strait Islander People
What is Care Coordination and Supplementary Services (CCSS)?
The CCSS program is a Commonwealth funded initiative to assist Aboriginal and Torres
Strait Islander people with chronic disease to better access specialist and allied health
services. The CCSS program identifies Aboriginal and Torres Strait Islander clients with
complex chronic disease needs and assists them with managing their disease. CCSS will
provide the client with a dedicated Care Coordinator who will work closely with them, their
GP, the practice nurse, other community services and allied health professionals. This
service is free for eligible clients.
Who is eligible to be part of this program?
This program is open to Aboriginal and Torres Strait Islander people who:
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have one of the following chronic diseases: cardiovascular disease, diabetes, cancer,
chronic respiratory disease, chronic renal disease
have a current MP in place
have a referral from their GP to the CCSS program
have complex needs which require support and assistance.
How can Care Coordinators assist?
The Care Coordinators are registered nurses who can:
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coordinate the health services involved in client care
help to arrange and manage health appointments
organise client transport for appointments
assist with client understanding of chronic conditions and care plan
liaise with GPs, specialists and any other health providers
improve the overall health of the patient
link clients to other services
access supplementary services where needed
provide feedback to your GP/work in collaboration with your GP
encourage and support patient chronic disease self-management.
What is supplementary services funding?
Supplementary services (as part of the CCSS program) is a limited pool of funds available to
Care Coordination patients. This funding is used to assist Aboriginal and Torres Strait
www.nmml.org.au
216 Lower Heidelberg Road Ivanhoe East VIC 3079
PO Box 2209 Ivanhoe East VIC 3079
t 03 9490 2700 f 03 9497 4192
ABN 23 152 639 962
Medicare Locals gratefully acknowledge the financial and other support from the Australian Government Department of Health and Ageing
GP FACT SHEET
Islander patients with the highest health care need to better access specialist and allied
health services as clinically required. Funds may be used to:
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assist with transport costs to appointments (where other transport is not appropriate/
available)
cover allied health provider fees (where MBS rebates are not available)
cover the gap between MBS rebates and private specialists or allied health providers
cover the cost of urgent specialist appointments (where public wait times are not
clinically appropriate)
purchase medical aids (as per CCSS guidelines):
 dose administration aids (DAAs)
 assistive breathing equipment (including asthma spacers, nebulisers, masks
for asthma spacers and nebulisers, continuous positive airways pressure
(CPAP) machines, accessories for CPAP machines
 blood sugar/glucose monitoring equipment
 medical footwear that is prescribed and fitted by a podiatrist.
 dietary supplements (e.g. Sustagen) as recommended by a healthcare
professional
 nutritional cookbooks/resources as recommended by a healthcare
professional.
NB: Funding may be used for other urgent items/needs, subject to assessment and approval by the CCSS team.
Supplementary services CANNOT be used to purchase the following services/items/aids:
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services when other publicly funded services are not available
surgical procedures and other acute care needs (supplementary services funding is
restricted to funding primary care follow-up services)
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medications
payment of the PBS co-payment gap
medical aids such as dentures, glasses, dressings, orthotics, webster packs and
nurses kits.
How do I refer to CCSS?
Complete a simple referral form for the NMML CCSS program available on the NMML
website: nmml.org.au
Or alternatively contact the NMML Care Coordinators:
Claire Rochford
Senior Care Coordinator
m 0407 803 349
e crochford@nmml.org.au
Jodie Frassenei
Care Coordinator
m 0419 276 229
e jfrassenei@nmml.org.au
www.nmml.org.au
216 Lower Heidelberg Road Ivanhoe East VIC 3079
PO Box 2209 Ivanhoe East VIC 3079
t 03 9490 2700 f 03 9497 4192
ABN 23 152 639 962
Medicare Locals gratefully acknowledge the financial and other support from the Australian Government Department of Health and Ageing
GP FACT SHEET
What is the Aboriginal Outreach Worker service?
The Aboriginal Outreach Worker is engaged by the Northern Melbourne Medicare Local
(NMML) to establish links with local Aboriginal people and communities in the region. The
Aboriginal Outreach Worker encourages and supports access to a range of health services
to reduce the burden of chronic disease as part of the Closing the Gap Program under the
supervision of the Indigenous Health Project Worker. The worker is available to attend
appointments with clients who require support, and can check in to see if clients need
referral to other community based services. This includes support to:
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register under the PIP Indigenous Health Incentive
attend appointments with GPs, nurses, allied health providers, specialists and
hospitals.
collect prescription medications from the chemist (emergency only)
provide clients with healthcare resources and information
link with relevant healthcare providers
link with relevant services such as social and emotional wellbeing services
work with Care Coordination services where needed.
NB: The Aboriginal Outreach Worker does not provide transport for clients.
How do I refer to the Aboriginal Outreach Worker?
Complete a simple referral form for the NNML Outreach Worker available on the NMML
website: www.nmml.org.au
Or alternatively contact the NMML Outreach Worker:
Nina Kirby
Aboriginal Outreach Worker
m 0408 387 456
e nkirby@nmml.org.au
Please note all referrals for this service will be accepted including self-referrals, GP referrals,
community service referrals and any other service providers.
www.nmml.org.au
216 Lower Heidelberg Road Ivanhoe East VIC 3079
PO Box 2209 Ivanhoe East VIC 3079
t 03 9490 2700 f 03 9497 4192
ABN 23 152 639 962
Medicare Locals gratefully acknowledge the financial and other support from the Australian Government Department of Health and Ageing