Service Coordination

Service Coordination Practice Resources
The Department of Health and Human Services provide links to a number of useful Service Coordination Practice resources including the Victorian Service Coordination Practice Manual, Good Practice Guide, Continous Improvement Framework and information on Privacy and Consent and Care Planning.

Service Coordination Tool Templates (SCTT)
SCTT is a suite of templates developed to facilitate Service Coordination Practice.

Service Coordination Online Learning Module
This e-learning tool supports the use of SCTT. Organisations are encouraged to include this module in their staff orientation. Experienced SCTT users may use this to refresh their knowledge and keep updated with recent changes.

Service Coordination Continuous Improvement Framework
This tool is designed to assist agencies in implementing service coordination.

Integrated Chronic Disease Management

Advance care planning
The Department of Health and Human Services website offers a range of resources to assist both consumers and professionals with Advance care planning. The site provides an overview of why advance care planning is important, offers best practice information, details legislation and offers tips for initiating and implementing advance care planning.

Chronic Disease Management Clearinghouse
The Integrated Chronic Disease Management Online Clearing House is a resource to support the work of all providers of integrated chronic disease programs and initiatives. The Clearing house allows authors to upload resources and tools that in turn can be accessed by others. The intent of the Clearing house is to reduce duplication of and increase access to practical tools and resources for all health services.

Integrated Chronic Disease Management (ICDM) strategy in Victoria
The Department of Health and Human Services website provides an overview of the Integrated Chronic Disease Management (ICDM) strategy in Victoria. It also provides information on chronic care forums that bring together organisations managing chronic diseases, to explore issues and learn from each other’s experiences.

Wagner Chronic Care Model

The Wagner Chronic Care model is an evidenced based framework for chronic illness. This framework has been endorsed by the Victorian Department of Health and Human Services Primary Care Branch.

The Wagner Chronic Care Model identifies 6 essential elements for improving chronic care:

  1. Community resources
  2. Organisation of healthcare systems
  3. Self-management support
  4. Decision support
  5. Delivery system design
  6. Clinical information systems

The model is built on the premise that these six elements work together to create productive interactions between an informed, activated patient and a prepared, proactive practice team – which is what leads to improvements in outcomes.


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