This service is free and available across all ten local government areas in south eastern Melbourne: Glen Eira, Port Phillip, Mornington Peninsula, Casey, Stonnington, Greater Dandenong, Kingston, Bayside, Cardinia, Frankston.   

Patients living in south east Melbourne are eligible for this service if they are 18 years or older and identified as at risk of hospital admission and presentation to Emergency Departments (ED), particularly in the afterhours period for reasons that may include any of the following: 

• Have two or more chronic conditions (such as arthritis, asthma, back pain, cancer, cardiovascular disease, diabetes and mental health conditions) 
• Have one or more chronic conditions and are from one of the following priority groups: Aboriginal and/or Torres Strait Islander, at risk or experiencing homelessness , culturally and linguistically diverse, have a mental health condition 
• Have not been keeping their appointments  
• Display tendency to medicalise their social issues  
• If known by the referrer and are disengaged from primary health and have been recently discharged from hospital or ED (frequent attendees) and not involved in any other program; or
• Have had a minimum of two potentially avoidable hospital admissions over a 12 month period 

Feel confident that your care plan and clinical advice is being implemented.  Benefits include: 

• Coordination complements care plans provided by you 
• Patients receive after-hours care in between GP visits 
• Be updated on patient progress and activity 
• More time to support more patients 
• Care coordinators are experienced social workers and registered nursing staff  
• Simple referral process 
• Free service for participating general practices and patients 

Patients will receive tailored care in between GP visits. Benefits include: 

• Free care coordination tailored to their needs, including access to a care coordinator who will work with them to identify their goals and meet these 
• Online or face-to-face appointments in home or a safe place of choice 
• Time with clinical staff to review, progress and address clinical and social needs prescribed by their GP 
• Explore and book social services and programs to support overall wellbeing 
• Assistance with referrals, filling prescriptions, booking appointments and transport  
• Reminders for GP and healthcare appointments  
• Up to three months of support Retain your own GP Feel confident that your care plan and clinical advice is being implemented.