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Team Care Coordination program

The Team Care Coordination program is a free service for people over the age of 18 with complex and chronic health conditions. It supports people to remain living at home by improving their self-management and quality of life.

Older gentleman in care WEB RGB

Supporting you to live well -
your home, your health, your way

The program offers health education, assessment and coordination of health and community services delivered by clinical nurses through face-to-face in-home visits, telehealth and phone consultations for up to three months which can be extended as needed.


People are eligible for Team Care Coordination if they:

  • have a least one complex chronic health condition
  • live within the North Brisbane and Moreton Bay region
  • have a GP who works within the North Brisbane and Moreton Bay region (preferably)
  • have been verbally referred to the program by a health professional
  • are not living in an aged care facility or receiving comprehensive funding packages.

Referral process

The program accepts referrals from the Metro North Hospital and Health Service under the Staying Healthy, Staying Home program, GPs, community clinicians, people living with chronic health conditions and Queensland Ambulance Service.

Referrals can be submitted to the central intake service by:

  • fax: 07 3630 7808
  • Medical Objects software
  • Metro North HHS refer software
  • phoning the Service Navigation line on 1800 250 502.

*Referrals are active for 12 months

To find out more, download the Team Care Coordination patient and GP information brochures

To refer your client, select a referral form below:

GP e-referral templates

Importing instructions for medical software

Queensland Health Team Care Coordination referral form

Community Health Providers Team Care Coordination referral form

Need help?

Service Navigator is a helpline available to health professionals for advice and information about health and community services available throughout north Brisbane and the Moreton Bay Regional Council areas.

For more information or to discuss a referral, contact our Service Navigator on 1800 250 502.

Team Care Coordination program is funded by Metro North Hospital and Health Service.