Care Coordination Service (CCS)
About Us
The Care Coordination Service (CCS) is a community-based social prescribing program delivered by Footprints Community for adults living with chronic health conditions who experience additional bio-psychosocial challenges that affect their ability to manage their health.
CCS supports individuals with one to four chronic conditions who are considered at rising risk of hospitalisation but are not currently frequently hospitalised. The program works alongside a person’s General Practitioner, who remains responsible for clinical care, while CCS focuses on addressing non-clinical factors impacting health outcomes.
Delivered by skilled Link Workers, the program provides personalised support to strengthen self-management, improve system navigation, and connect participants with appropriate health, community, and social supports. CCS adopts a strengths-based, client-centred approach to improve independence, wellbeing, and coordination of care
Contact Us
Organisation:
Office Address:
Website:
Call Us:
Email:
Footprints Community
213-217 St Pauls Ter, Fortitude Valley QLD 4006, Australia
1800 366 877
Program Details
Accessibility Features:
Transport/Parking Details:
The program offers interpreter services where required and provides flexible engagement options, including phone-based and community-based support. Assistance is tailored to individual cultural, language, health, and mobility needs to ensure equitable access. The service also supports participants to navigate complex systems such as the NDIS, My Aged Care, and Centrelink.
Target Audience:
The program supports adults living with chronic health conditions who experience social, financial, cultural, or environmental barriers that impact their ability to manage their health. Participants may be living in isolation or experiencing complex life stressors such as housing insecurity, caring responsibilities, or language barriers. The Care Coordination Service (CCS) particularly supports individuals who would benefit from structured care coordination and practical support to navigate health, community, and social care systems.
Eligibility Criteria:
Participants must be aged 18 years or older and have between one and four chronic health conditions, with the primary presenting concern not being mental health related. They must be experiencing bio-psychosocial risk factors that impact their capacity to manage their health conditions and be considered at rising risk of hospitalisation, but not currently experiencing frequent hospital admissions. Participants are required to have a General Practitioner as their primary clinical care provider and reside in the Brisbane South PHN metropolitan region. Referrals must be made by an accepted referrer, including General Practitioners, Practice Nurses, hospitals, Community Health Hubs, Nurse Navigators, Aged Care Navigators, or pharmacists. Self-referrals are not accepted for this program.
Delivery Modes:
Cost:
In Person, Online, Telephone
Free (no cost to participants)
Where To Find Us And Our Service Coverage Area
Serviced Postcodes:
4068, 4073, 4074, 4075, 4076, 4077, 4078, 4101, 4102, 4103, 4104, 4105, 4106, 4107, 4108, 4109, 4110, 4111, 4112, 4113, 4114, 4115, 4116, 4117, 4118, 4119, 4120, 4121, 4122, 4123, 4124, 4125, 4127, 4128, 4129, 4130, 4131, 4132, 4133, 4151, 4152, 4153, 4154, 4155, 4156, 4157, 4158, 4159, 4160, 4161, 4163, 4164, 4165, 4169, 4170, 4171, 4172, 4173, 4174, 4178, 4179, 4183, 4184, 4205, 4207, 4270, 4275, 4280, 4285, 4287
For any inaccuracies or updates needed on this page, please reach out to the ASPIRE team.