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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.

Middle aged woman and elderly woman WEB RGB

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

Team Care Coordination is a service delivered by Allied Health and Clinical nurses that are able to offer health education and coordination of health and community services. The team will be able to assist following a face to face in-home visit, telehealth or phone consultation to gain a good understanding of your needs and goals. The team offer ongoing support and contact for up to three months, which can be extended if needed, with the aim of improving quality of life and self management.


Are you eligible for the program?

People are eligible for Team Care Coordination if they:

  • have a chronic health condition that is impacting their life
  • live within the North Brisbane and Moreton Bay region
  • have a GP that works within the North Brisbane and Moreton Bay region (preferably)
  • are not living in an aged care facility or receiving comprehensive funding packages.

How to access/refer to the program

The program accepts referrals from people living with chronic health conditions directly. It also accepts referrals from Metro North Hospitals and Health Service under the Staying Healthy Staying Home program, Queensland Ambulance Service, GP’s, Practice Nurses and Community clinicians.

Referrals can be submitted to the central intake service by:

  • phoning the Service Navigation line on 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 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.