Service System Coordination and Integration

Access and Support Multicultural Program - Northern Health

Northern Health CALD Access and Support Program

If you have any CALD clients that referrals have been made and are resistive to service - referral to the Access and support program can assist for service provision uptake. Also for CALD clients that are resistive to service or declined service or any recommendations perhaps a referral to this program would also benefit.

Currently Northern Health can accept clients same day and proceed to a home visit in a responsive manner – there is no waitlist.

Referrals can be made via My Aged Care.

NEPCP Care Plan Readiness Checklist 2011

Please refer to the attached Checklist.

Improving Coordination of Diabetes Care in North East Melbourne - North East Adult Diabetes Triage Tool and Patient Diabetes Services at Community Health Services Brochure

The North East of Melbourne has seen dramatic increase in the prevalence of diabetes over the last decade. In response to this, GPs and health agencies in the North East Primary Care Partnership are working together to improve the integration of diabetes care across the catchment. The aim is to improve the knowledge of diabetes services in the area so that people with diabetes are  provided the level of care that best meets their needs.

North East Diabetes Referral Form - Medical Director

Please refer to the form attached below.

North East Diabetes Referral Form - Best Practice

Please refer to the form attached below.

Health & Wellbeing Support Plan Brochure

Through the Electronic Care Planning Project, a group of consumers have developed this brochure to help staff explain to consumers what a Support Plan is and how it will support their care.

NEPCP will have a limited number of printed copies available to member agencies, or print and copy the attached version. If you would like copies please contact


Palliative Care Services Summary (2014) for the north and west metropolitan region

The North and West Metropolitan Region Palliative Care Consortium has updated the Palliative Care Services Summary (2014) for the north and west metropolitan region.

It provides a summary of Palliative Care services offered in the region. If you have a previous version (2013), please update with the 2014 version as there have been a number of changes.

A new addition is a page of clinical indicators which may assist in identifying if a person requires specialist palliative care.

SCTT Online Training Module

The Service Coordination Tool Templates (SCTT) Online Training Module is an e-learning tool designed to support the use of SCTT. Organisations are encouraged to include this module into their staff orientation. Experienced SCTT users may use this e-learning tool as a means of refreshing their knowledge, or as a mechanism to keep updated with the changes to the SCTT 2012.

Service Coordination Online Training Module

The Service Coordination Online Training Module is an e-learning tool to support the practice of Service Coordination in Victoria. Organisations are encouraged to use this module to orientate staff to Service Coordination practice within their organisation and use it for professional development for existing staff.

The module can be found at the following link:

Presentations from Service Coordination Workshop - May 16th 2013

On May 16th the NEPCP facilitated a workshop on Service Coordination. The workshop was attended by 26 workers from a range of services including mental health, HARP, local government, community health and CALD.

Presentations from the session are now available below:


Guidelines on Feedback to GPs

The NEPCP is pleased to release an update of the “Guidelines on Feedback to GPs” that have been developed with member agencies.

The Guidelines aim to improve communication about the care of consumers shared between health and community professionals and general practitioners (GPs). 

They will enhance the quality of care and experience of consumers, particularly those with long term or complex conditions.

Living with a Chronic Condition: Getting the Right Help, in the Right Place at the Right time for your Patients

To help GPs match patient needs with the appropriate service, referral and access to programs for people with chronic disease have been streamlined in Banyule, Nillumbik and Darebin.

Use the attached brochure to assist you to identify the level of care your patient needs and the organisation that provides the most appropriate services to meet these needs.

Victorian Service Coordination Practice Manual

The Victorian Service Coordination Practice Manual (VSCPM) and associated resources have been designed
for managers and service providers involved in the implementation of service coordination. Initially developed
in 2006 by the statewide Primary Care Partnership (PCP) Chairs’ Executive, with funding from the Department
of Health, the resources now aim to provide an overarching service coordination framework applicable
to a range of sectors and services.

Service Coordination Tool Templates (SCTT) 2012

The Service Coordination Tool Templates (SCTT) is a suite of templates developed to facilitate and support service coordination. The SCTT support the collection and recording of initial contact, initial needs identification, referral and coordinated care planning information in a standardised way. Using the SCTT can improve communication between service providers, the recording of information generated by screening and assessment processes, information sharing, and the quality of referrals and feedback between service providers.

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