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.   

All people aged 18 and over (15 and over for Aboriginal and Torres Strait Islanders), living in the above listed LGAs, with a chronic condition or complex needs, and limited access to multidisciplinary care are eligible for this program.

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

• Coordination complements care plans provided by you
• Patients receive care in between GP visits
• More time to see other patients
• No cost to general practices or patients
• GPs retain all eligible MBS billing for their patients
• Receive regular updates on patient progress and activity
• The service consists of experienced social workers, allied health professionals and registered nurses.  
• Eligible patients are linked to social services such as Centrelink, and the Department of Families, Fairness and Housing
• Simple referral process

Patients will be supported in their community in between GP visits. Benefits include:

• Free care coordination tailored to their needs
• Time with clinical staff to review, progress and address clinical and social/lifestyle needs prescribed by their GP
• Online or face-to-face appointments at home or a safe place of choice
• Help exploring and booking 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 their own GP