A free program helping people with chronic and complex health conditions stay well and connected to care.
The Care Coordination Support Service (CCSS) helps people living with chronic illness or complex health conditions manage their care and stay connected to the services they need.
Delivered by
Silverchain and funded by South Eastern Melbourne PHN, the service supports patients to achieve their health goals.
Where is this service provided?
The free service is available across all ten local government areas in south east Melbourne:
- Glen Eira
- Port Phillip
- Mornington Peninsula
- Casey
- Stonnington
- Greater Dandenong
- Kingston
- Bayside
- Cardinia
- Frankston.
Who is eligible?
People who:
- Are 18 years or older (or 15 years and over for Aboriginal and Torres Strait Islander people)
- Have a chronic condition or complex health need
- Have limited access to multidisciplinary or community health care
- Live in one of the eligible LGAs.
(Note: permanent residents of residential aged care facilities, people eligible for DVA care coordination, or recipients of palliative care services are not eligible.)
What support is provided?
CCSS offers up to three months of tailored care coordination, provided by registered nurses and allied health professionals. Support is delivered via phone, video, or in-person visits, depending on the person’s needs.
The service helps patients:
- Stay connected to care between GP visits
- Understand and follow their GP’s advice
- Access community, social, and allied health services
- Navigate programs such as My Aged Care, Home and Community Care for Younger People, and the National Disability Insurance Scheme (NDIS)
- Explore options for transport, social supports, and funding assistance
- Look for alternative solutions when there are long waiting times for services
- Stay motivated and on track with their health and lifestyle goals.
Care coordinators also maintain regular communication with the patient’s GP and care team, ensuring everyone works together toward shared health goals.
Why is this program needed?
According to SEMPHN’s 2024 Health Needs Assessment, chronic conditions are the leading cause of illness, disability, and death in south east Melbourne. Many people with multiple chronic conditions struggle to manage their care, connect with the right services, or understand the health system.
The CCSS program helps bridge this gap by providing ongoing, practical support that complements GP care and keeps people well in their homes and communities.
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The CCSS is delivered by
Silverchain and funded by South Eastern Melbourne Primary Health Network.
