Team Care Coordination

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

The Team Care Coordination program supports people in our region who have complex chronic health conditions. Care coordination services are provided to patients referred by their GP, Metro North Health and the Queensland Ambulance Service.

Traditionally a clinical nurse led service, this year the program has expanded with the employment of an allied health coordinator to be able to address occupational therapy needs for the clients most at risk.

To provide workload relief for GPs and ensure clients don’t miss out on accessing this service, in 2020/21 the service added a pathway for people to self-refer via the Service Navigation phone line following recommendation by their primary health professional.

Clients receiving care at Metro North Health facilities who do not require urgent complex clinical services but who may benefit from support at home can be referred to Team Care Coordination through the Staying Healthy, Staying Home program.

The Queensland Ambulance Service makes referrals to the service as part of a Community Falls Follow-up project, an initiative with Community and Oral Health (Metro North Health) that is improving patients access to post falls management and care coordination.


195 GPs and 175 clinicians from the hospitals in the region were referring to Team Care Coordination.


1,963 referrals were received with 1,316 of these patients consenting to receive services from Team Care Coordination.



732 of these referrals came from the Team Care Coordination referral stream, 978 from the Staying Healthy Staying Home referral stream and 262 from the Queensland Ambulance Service.

Community Falls Follow Up program

Pictured above L-R: Matt Green (Queensland Ambulance Service), Kate Schultz (Metro North HHS), Sharon Gavioli (Brisbane North PHN), Mary Wheeldon (Metro North HHS), Dr Robert Franz (Metro North HHS) and Mark Butterworth (Metro North HHS). The Community Falls Follow Up program was runner-up in the Excellence in Integrated Care award category at the Metro North Staff Excellence Awards in 2020. 

Dementia care in the North Brisbane and Moreton Bay region

The Brisbane North Dementia Care program engaged consumers, carers and health service providers in dementia awareness, workforce development and education activities. A regional strategy for living well with dementia was completed and has guided the implementation of targeted activities

A total of 40 GPs received training in recognising, diagnosing and managing dementia in general practice; 29 practice nurses attended workshops on understanding dementia; and a series of nursing education events targeted at residential aged care facilities attracted 210 nurses.

The PHN worked on the creation of an online dementia service navigation platform and hardcopy directory, to improve dementia service navigation across the North Brisbane and Moreton Bay region.

Visit to find out more.

Improving the care journey for people living with chronic wounds

The PHN funded the delivery of evidence based chronic wound management education together with clinical mentoring support, for staff working in residential aged care facilities and aged care community service providers. This three year initiative finalised in June 2021.

452 nursing staff received formal education; including 12 people who completed a clinical placement at a Brisbane wound clinic, 41 people completed an online wound education course and 399 people received training across 16 wound management workshops.

790 specialist wound consultations were also delivered for 191 patient referrals, as part of a coaching and mentoring initiative. The initiative reached 30 RACFs and 10 community care providers.

Wound care

Improving the care journey for people receiving palliative care

With a commitment to increasing the capacity of nurses in our region to respond to the palliative care needs of the community, we provided funding to eight registered nurses to undertake either a Master of Nurse Practitioner or Graduate Certificate in Palliative Care with the final student graduating in June 2021.

We also funded a community of practice in palliative care to enhance patient care through building connections and sharing knowledge amongst registered nurses.

Other workforce initiatives delivered include:

  • commissioning Change Futures to deliver psychosocial palliative care training for RACF nursing staff, with 14 RACFs enrolled in this initiative in 2020/21
  • facilitating the Brisbane North Community Palliative Care Collaborative which identifies gaps and areas for improvement in palliative care service delivery.
Palliative care

Coordinated care for older people