Care Coordination and Supplementary Services (CCSS)

The Commonwealth Government is contributing $805.5 million over 4 years towards the Indigenous Chronic Disease Package. This follows the agreement from the $1.6 billion National Partnership in 2008 on Closing the Gap in Indigenous health outcomes that will reduce chronic disease factors, encourage earlier detection and better management of chronic disease in primary care services, improve follow-up care and increase the capacity of the primary care workforce to deliver effective health care to Aboriginal and Torres Strait Islander people.

About the Program

The aim of the CCSS Program is to contribute to improve health outcomes for Aboriginal and Torres Strait Islander people with chronic health conditions through better access to coordinated and multidisciplinary care.

Definition of Care Coordination

Care coordination means working collaboratively with patients, general practices and Aboriginal health services to assist in the provision of care and services that facilitate an Aboriginal person over 15 with a chronic condition to manage their health in a way that will result in the optimum health outcome for them.

The Care Coordinator’s role will be to:

• promote the CCSS program to general practices and AMS;
• arrange services as per care plan;
• arrange transportation to appointments;
• encourage patients to attend regular reviews; and
• assist patients in adhering to treatment regimes, develop self management skills and connect with community support.

Referrals

 The CCSS program is available for Aboriginal adults (15 years and over) with a chronic disease and a Care Plan (GPMP and/or TCA) in place from their regular GP. 

For the purpose of the program and consistent with the Medicare Benefits Schedule, a chronic disease is one that has been, or is likely to be present for at least 6 months.

The CCSS program will target diabetes, cardiovascular disease, chronic respiratory disease, chronic renal disease and cancer.

Patient Eligibility

To be eligible for care coordination under the CCSS program, Aboriginal and Torres Strait Islander patients who are over 15,  must have a care plan in place, be enrolled for chronic disease management in a general practice or Aboriginal health service participating in the PIP Indigenous Health Incentive and be referred by their usual GP.

Patients most likely to benefit from the service include:

• Patients who are at greater risk of experiencing otherwise avoidable (lengthy and/or frequent) hospital admissions;
• Patients who are not using community-based services appropriately or not 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 and Aboroginal health service staff;
• Patients who are unable to manage a mix of multiple community-based services;
• Patients who do not comply with medicine regimes; and
• Patients who have lack of understanding on their chronic disease and would benefit from more intensive education.

Additional Information

Additional information about the Commonwealth’s Indigenous Chronic Disease Package can be found at
http://www.health.gov.au/tackling-chronic-disease

Templates and Resources

CCSS fact sheet for GPs: CCSS fact sheet for GPs

CCSS Referral Form: CCSS referral form or (if unable to open Word doc) CCSS referral form

CCSS Consent template: CCSS Consent-template or (if unable to open Word doc) CCSS Consent-template PCEMML