The healthcare system in Victoria provides health treatment, care, education and disease prevention.
It includes a wide range of healthcare professionals, all working in numerous public and private settings, such as hospitals, medical clinics, community centers and private practice including;
- public and private hospitals
- general practice clinics
- public and private specialist clinics and consulting rooms
- maternity services, such as public and private maternity hospitals, and birthing units
- aged care facilities, such as nursing homes
- community centres, such as maternal and child health centres
- dental clinics, both private and public hospital based
- community-based support services, such as Hospital in the Home
- carers, both unpaid and professional, and volunteers
- phone and internet services, such as NURSE-ON-CALL and online counselling
- specialty healthcare professionals in private practice, such as physiotherapists and dietitians.
Integrated Care is the organisation and management of services so that people get the care they need, when they need it, in ways that are user friendly, achieve the desired results and provide value for money (World Health Organisation).
This should be:
- Comprehensive – meeting all relevant health and social care needs
- Coherent – making sense to those providing and receiving care
- Well coordinated – convenient, avoid duplication and not wasting time for all involved
- Person or community centered – taking account of the reality of people’ lives
Service Co-ordination
Service co-ordination is a collaborative approach that actively involves the patient, their family, carers, support people and service providers to ensure the best possible outcomes for the patient.
It can be applied at all points along the care pathway and is particularly important for people with complex needs such as chronic conditions.
Service coordination aims to place consumers at the center of service delivery. It ensures that they have access to the services they need, provides opportunities for early intervention, health promotion and improved health outcomes.
From a client perspective, coordination between services enhances the quality of their care and provides a level of service more sensitive to their personal circumstances.
UPDATED – MEMORY SUPPORT GUIDES for the Grampians region
The Memory Support Guide is a comprehensive guide to support people within the Grampians region to live well with memory changes and dementia.
This guide has been based on a previous guide, Grey Matters (2012), which was funded by the Victorian Government Department of Health and Human Services. Grey Matters has been a valuable resource for the community however with the transition to My Aged Care and the introduction of the NDIS in recent times, an update was needed to reflect the changes to the service system and referral pathways.
Three Memory Support Guides were developed to reflect the three areas across the Grampians Region. They were developed in partnership by Wimmera PCP, Central Highlands PCP and Grampians Pyrenees PCP with the support of the Grampians Sector Development Team.
Hard copies of the guides are available from our office or electronically by clicking on the image below:
If you have questions or have suggested changes, please contact Grampians Pyrenees PCP on 5352 6226 or email admin@gppcp.org.au
Secure Electronic Sharing of Patient Care
The sharing of secure electronic patient information assists health services to provide patients the care they need by sharing patient information in a timely, appropriate, coordinated and collaborative way.
Consistent shared care communication between health services results in:
- Reduced duplication of management plans, tests and personal history information provided by the patient
- Improved response times to requests for information and referrals
- Patients receiving the services they need, when needed
- Co-ordinated care that is accessible and seamless
- Clarity as to who is involved in patient care
- Reduced duplication of assessments and services and improved identification of service gaps
- Improved knowledge of the local service system and access to appropriate resources
- Secure and efficient transfer of patient information, compliant with Privacy Legislation
The Commonwealth Home Support Programme (CHSP)
The CHSP is one of the changes being made by the Australian Government to the aged care system to help older people stay independent and in their homes and communities for longer. The CHSP is one consolidated programme that provides entry-level home support for older people who need assistance to keep living independently at home and in their community. Carers of these clients will also benefit from services provided through the CHSP.
http://wimmerapcp.org.au/commonwealth-home-support-programme/
The HACC Program for Younger People (HACC PYP)
The HACC PYP provides basic support and maintenance services to help people (aged under 65 and under 50 for Aboriginal people) with disabilities remain living at home as independently as possible.
http://wimmerapcp.org.au/hacc-and-community-aged-care/
SCTT Referral Tools
The SCTT online module is an e-learning tool to support the use of the SCTT. The department encourages service providers to include this module in their staff orientation. Experienced SCTT users may use this e-learning tool to refresh their knowledge, or to keep updated with the changes in SCTT 2012.
If you would like to learn more about service coordination practice in general, you can complete the Service coordination online learning module.
http://elearning.health.vic.gov.au/sctt/
If you would like to download copies of the SCTT templates please go to
The Wagner Chronic Care Model (CCM)
The “Wagner Chronic Care Model (CCM)” identifies the six essential elements of a health care system that encourage high-quality chronic disease care. These elements are the community, the health system, self-management support, delivery system design, decision support and clinical information systems.
