Service summary

Building on the success of the Integrated Team Care services, COORDINARE has partnered with the Silverchain Group to expand access to the care coordination services across South Eastern NSW.

The Chronic Care Coordination program is available for people with a chronic health condition and complex health needs.

It provides support to patients who need help to manage their condition including, understanding their condition, assistance appointments, organising transport, as well as providing regular follow-up and feedback to the GP.

You can access and download information for referrers or consumers.

Grand Pacific Health's Chronic Pain Program offers support for people with mild to moderate chronic pain.They offer a range of education and therapy options, including:

• Online group program - Pain Explained: this is a 6-week program of 90-minute sessions run by Dr Adele Stewart. There are 3 rounds of the program over the financial year.

Learn more about the program and enquire about joining the online sessions here.

• Individual consultations: with members of GPHs multidisciplinary team.

Learn more about the consultations here.

The National Dementia Helpline provides free and confidential support for individuals affected by dementia.

You can contact them at 1800 100 500, available 24 hours a day, 7 days a week. The helpline offers expert information, advice, and connections to community support services and government programs.

Supporting people with dementia and their care network. When a person living with dementia is experiencing changes to their behaviour, we work with you to understand the causes – and help you improve their quality of life.

Dedicated helpline 24 hours a day, 7 days a week - 1800 699 799.

Trained dementia consultants work with you, so you receive the right support at the right time.

Nationwide service that goes wherever you are. Including rural and remote Australia.

Sole entry point to access the Specialist Dementia Care Program.

How Dementia Support Australia can support you: watch video.

Gateway Life are offering free access to an 8-week gym-based program combining exercise and education for people aged 45 and over who are at risk of developing chronic conditions.

Participants will attend weekly group sessions, alternating between physical activity and education. The education component will focus on the role of exercise and nutrition in managing chronic disease risk, while also building digital health literacy to help individuals better understand and navigate the healthcare system.

Delivered by qualified Allied Health professionals the program will be delivered from Gateway Life’s facilities in Wollongong and Nowra.

Grand Pacific Health is a not-for-profit, primary health care organisation providing locally-tailored, high-quality services.

Services include physical health, mental health, youth health, Aboriginal health and chronic disease management.

GPH covers a large portion of South Eastern NSW, with over 20 hubs including 6 headspace centres and 2 GP clinics in Shell Cove and Nowra.

For more detailed information about specific services please visit the Grand Pacific Health website.

In partnership with COORDINARE, Healthy Cities Australia have expanded their successful health promotion initiatives community walking groups and Cook Chill Chat. The expansion increases access to the programs across the Illawarra Shoalhaven and will see the programs delivered in Southern NSW (Queanbeyan and Goulburn) for the first time.

These programs promote social connection and healthy lifestyle changes. Learn about the different programs below:

Cook Chill Chat - is a cooking program that fosters social connections and promotes physical and mental wellbeing. The 6-week program brings members of the community together to cook and share a meal, providing the opportunity for increased social connections, improved cooking skills, improved healthy eating knowledge, and awareness of health risk factors. Click here to learn more and get involved > https://healthycities.org.au/programs/cook-chill-chat/

Community Walking Groups - 5x5 and 3x3 are free non competitive community walking events covering either a 5km or 3km course, once for 5 weeks (or 3 weeks respectively). The programs provide a safe and friendly opportunity to be active and connect with others in your community. Click here to learn more and get involved > https://healthycities.org.au/programs/community-walking-programs/ plu a youtube link > https://youtu.be/ETxpRoiXv44

Healthy Hearts Healthy Minds is a free program, provided by Silverchain, aimed at improving cardiovascular health and overall wellbeing through proactive, community-based care.

As a part of this program, Silverchain's experienced nurses will collaborate with local GPs to assess eligible patients for an assessment using the Heart Foundation’s Heart Health Check Toolkit to create action plans.

Silverchain nurses will connect patients to services and supports including health coaching, empowering patients to better self-manage their heart health.

They will also refer patients to community care providers including dieticians and exercise physiologists, recommend support programs such as walking groups, share resources via digital platforms, and coordinate with other health care providers to ensure patients receive the best care.

This service is provided face-to-face and via telehealth where needed and is currently available at nine general practices across South Eastern NSW, including:

Braidwood Medical Centre > Gwynneville Medical Practice > Windang Family Medical Centre > Corrimal Family Medical > Kiama Doctors > Mulwaree Doctors > Sussex Doctors > Vincentia Bay Medical > Wollongong Doctors

A referral from a GP, who is based in South Eastern NSW is required to enrol on the Healthy Hearts Healthy Minds program.

Provides Aboriginal and Torres Strait Islander patients who have one or more chronic condition with a dedicated care coordinator to work closely with them and their care team, as part of ongoing care.

Eligibility criteria - For Aboriginal and Torres Strait Islander people with:

with one or more chronic conditions

are of any age, including children with early onset of chronic conditions

a current GPMP with or without TCA

are at risk of hospital admission due to their ill health

have trouble accessing and using the right services for their care

have trouble managing multiple services and appointments.

Referrals

Referrals can be sent to the preferred provider in your area:

Wollongong

Illawarra Aboriginal Medical Service

Grand Pacific Health

Nowra

Grand Pacific Health

South Coast Medical Service Aboriginal Corporation

Waminda – South Coast Women’s Health and Wellbeing Aboriginal Corporation

A GP Management Plan (GPMP) is required to access ITC. For referrals to a local AMS please ensure the GPMP is not completed at your practice. The AMS will complete the GPMP and enrol your patient into ITC. If the GPMP is completed at your practice the patient will not be able to access ITC via the AMS.

For referrals to GPH, please complete the referral form and send to the Intake Coordinator along with a Aboriginal and Torres Strait Islander Health Assessment (MBS 715) and GPMP. Ensure to include the care coordinator as part of the GPMP/TCA.

Visit HealthPathways for further detailed information.

The National Disability Insurance Scheme (NDIS) is the new way of providing disability support in NSW and around Australia.

The NDIS provides all Australians under the age of 65 who have a permanent and significant disability with the reasonable and necessary supports needed to enjoy an ordinary life.

Find out more at National Disability Insurance Scheme (NDIS) or by calling 1800 800 110.

Social Rx is a short-term program designed to link you to locally available support services and community-based resources using a social prescribing approach.

Primary and Community Care Services (PCCS) can help you to tackle the non-medical barriers to your health and wellbeing, issues such as housing, social and community networks, family relationships and other socioeconomic factors that you and your doctor cannot address alone.

They work with you to identify meaningful goals and a personalised plan to meet these needs while reducing isolation and disadvantage.

Ask your GP or health provider about this program and for a referral or reach out to Social RX for more information and to discuss access to the program.

Located at Milton Medical Centre, the South-Eastern NSW Endometriosis and Pelvic Pain Clinic offers assessment and diagnosis, support, and education via a multidisciplinary team, including doctors and a specialist nurse. Group education sessions are presented by a gynaecologist, physiotherapist, sexologist, psychologist, nutritionist, and meditation instructor. Designed as a consultative and support service patients are referred back to their regular GP for ongoing care. Patients can access the clinic by booking an appointment directly with Milton Medical Centre email: endo@miltonmedical.com.au or phone: 02 4455 5755. Telehealth is available for this service.