• Home
• Indigenous Chronic
  Disease Package
• Tackling Chronic Disease
  Risk Factors
  • National action to reduce Indigenous smoking rate
  • Helping Indigenous Australians to reduce their risk of chronic disease
  • Local Indigenous community campaigns to promote better health
• Improving Chronic Disease
  Management and Follow up
  • Subsidising PBS medicine co-payments
  • Higher utilisation costs for MBS and PBS
  • Supporting primary care providers to coordinate chronic disease management
  • Improving Indigenous participation in health care through chronic disease self management
  • Increasing specialist and allied health follow up care
  • Monitoring and evaluation
• Workforce Expansion,
  Training and Support
  • Workforce education and training
  • Expanding the outreach and service capacity of Indigenous health services
  • Engaging Medicare Locals to improve Indigenous Access to mainstream primary care
  • Attracting more people to work in Indigenous Health
  • Clinical practice and decision support

10. Care Coordination and SupplementaryServices¹ Program

1. Information for General Practitioners on the Indigenous Chronic Disease Package
2. Patient identification
3. Practice Incentives Program (PIP) Indigenous Health Incentive
4. Aboriginal and Torres Strait Islander health assessment items
5. MBS items overview
6. Chronic disease follow-up services
7. Allied health follow-up services
8. Practice nurses/Registered Aboriginal Health Worker follow-up services
9. Pharmaceuticals Benefit Scheme (PBS) Co-payment measure
10. Care Coordination and Supplementary Services Program (CCSS)

---

Who is this document for?

• General practices
• Aboriginal Community Controlled Health Services and other Indigenous Health Services

Background

The Australian Government’s Indigenous Chronic Disease Package supports Aboriginal and/or Torres Strait Islander people with chronic disease to better access specialist, GP and allied health services. Aboriginal and/or Torres Strait Islander people who are identified as needing more complex chronic disease management or support to access services can be referred to the Care Coordination and Supplementary Services Program (CCSS).

Patient eligibility

To be eligible for care coordination under the CCSS program, Aboriginal and/or Torres Strait Islander patients must:

• have a care plan;
• be enrolled for chronic disease management in a general practice or Indigenous Health Service participating in the Practice Incentives Program Indigenous Health Incentive; and
• be recommended by their General Practitioner.

Priority should be given to patients most in need of care coordination services to obtain improved health outcomes. As a guide, patients most likely to benefit from the service 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 or Indigenous Health Service staff; and
• Patients who are unable to manage a mix of multiple community-based services.

Provider eligibility

Only general practices or Indigenous Health Services participating in the PIP Indigenous Health Incentive (see Detail Card 3) are eligible to enrol patients in the CCSS Program. Care Coordination and Supplementary Services (CCSS) The CCSS program will contribute to improved health outcomes for Aboriginal and/or Torres Strait Islander people with chronic health conditions through the following two components:

1. Care coordination provided to Aboriginal and/ or Torres Strait Islander patients with a chronic disease.
2. Supplementary services that assist patients receiving care coordination under the CCSS program. Funds are available to provide access to medical specialists and allied health services that are in accordance with the patient’s care plan. The funds may also be used to assist with the cost of local transport to health care appointments.

The CCSS program will be implemented progressively through a staged approach and will not be available in all locations in the initial years of the program. Funds for the CCSS Program will be managed by the State Based Organisations of the Divisions of General Practice Network.

Supplementary services

When there is a barrier to care, such as lack of available appointments with a publicly funded provider or access to affordable local transport, providers may access the CCSS program supplementary services funding to expedite the patient’s access to these services in the private sector.

The supplementary services funding can be used flexibly to assist patients in the CCSS program to access medical specialists and allied health services where these services are in accordance with the patient’s care plan.

Priority allocation of supplementary services funding

The supplementary services pool cannot fund all of the follow-up care required by patients in the CCSS program. Pool funds should only be used where other publicly funded services are not readily available.

As the supplementary services funding is a limited resource, priority for the use of these funds should be given to responding to urgent needs. The funds should be used to purchase services that:

• Address risk factors, such as a waiting period for a service longer than is clinically appropriate;

• Reduce the likelihood of a hospital admission or shorten a patient’s stay in a hospital, and are not available through other funding sources; and

• Ensure access to a clinical service that would not be accessible because of the cost of a local transport service.

Further information

Additional information about the Australian Government’s Indigenous Chronic Disease Package can be found at: http://www.health.gov.au/internet/ctg/publishing.nsf/Content/improving-frontline-health and in the ICDP ‘Information for General Practice, Aboriginal Community Controlled Health Services and Indigenous Health Services’ booklet.

1. Department of Health and Ageing. MBS Online. Canberra: DOHA; 2010. Available at: www.health.gov.au/mbsonline

Back to Top

Page currency, Latest update: 09 December, 2010

• Useful links
• Contact us
• Copyright
• Linking to this site
• Disclaimer
• Privacy
• Accessibility