Team Care Coordination program
Supporting you to live well - your home, your health, your way
Team Care Coordination and our Service Navigation Line will be closed from Friday, 20 December 2024, and will reopen on Thursday, 2 January 2024. Referrals submitted during this period will not be actioned until we resume in the New Year.
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.
The service is delivered by clinical nurses and allied health that can offer health education and coordination of health and community services. Our team will:
- conduct a face-to-face in-home visit, telehealth, or phone consultation to understand your needs and goals
- offer ongoing support and contact for up to three months, with the possibility of extension if needed
- focus on improving quality of life and self-management.
Annual snapshot
Our Team Care Coordination annual snapshot for 2023/24 is now available, highlighting our team's impact and achievements over the past year.
We have created a Meet the Team video resource to provide more insight into our services and the role we play in chronic health education.
To find out more, download the Team Care Coordination patient and GP information brochures
Program information
People are eligible for Team Care Coordination if they:
- have a chronic health condition impacting their life
- reside within the North Brisbane and Moreton Bay region
- have a GP within the North Brisbane and Moreton Bay region (preferred)
- are not residing in an aged care facility or receiving comprehensive funding packages (those with comprehensive funding packages will be assessed on a case-by-case basis).
Referrals can be made by:
- individuals with chronic health conditions
- Metro North Health under the Staying Healthy Staying Home program
- community and oral health
- GPs, practice nurses
- community providers
Referrals can be submitted through:
- Phone: 1800 250 502 (Monday to Friday, 8:00 am - 4:00 pm)
- Metro North HHS Refer Software
- Medical Objects Software (Provider Number: MM4030000FT TEAM CARE, COORDINATION Practice Name: Brisbane North PHN)
- Fax: 07 3630 7808
*Referrals are valid for 12 months. Please be advised that we can only accept referrals submitted through secure channels
To refer your client, select a referral form below:
For more details or to discuss a referral, please contact us at:
- Phone: 1800 250 502
- Hours: Monday to Friday, 8.00 am - 4.00 pm
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.
Referral forms
For use by GPs and practice nurses.
To refer your client, select a referral template below:
Queensland Health Team Care Coordination referral form
For use by Queensland Health employees only.
Community providers Team Care Coordination referral form
For all other community providers.
Privacy
We take the protection of your personal information seriously.
Team Care Coordination program is funded by Metro North Health.
We acknowledge the Traditional Custodians within our region: the Jagera, Turrbal, Gubbi Gubbi, Waka Waka and the Ningy Ningy peoples of where we meet, work and learn. Brisbane North PHN is committed to reconciliation. Our vision for reconciliation is where the stories of our First Nations’ people are heard and shared, and networks are formed.