Team Care Coordination

Keeping people healthy and at home.

For over 20 years, Team Care Coordination has been providing care coordination services for patients with chronic conditions who are referred by their GPs. In more recent years, the Team Care Coordination has expanded the reach of the program and also provides care coordination services to patients referred by Metro North Hospital and Health Service clinicians and the Queensland Ambulance Service.

Patients receiving care at Metro North HHS 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 referrals are received under the Community Falls Follow-up project that aims to improve patients access to post falls management and care coordination.


In the 12 months between October 2019-September 2020*, 198 GPs and 143 clinicians from the hospitals in the region were referring to Team Care Coordination.


During October 2019-September 2020*, 1,905 referrals were received with 1131 of these patients consenting  to receive services from Team Care Coordination.


688 of these referrals came from the Team Care Coordination referral stream, 422 came from from the Staying Healthy Staying Home referral stream and 176 from the Queensland Ambulance Service stream.

* Please note the reporting period for Team Care Coordination program does not align with the financial year and instead runs from October 2019-September 2020.

Pictured above: Margaret Hilleard, recently hospitalised from a fall at the Prince Charles Hospital with Steven Miles MP; Metro North HHS Community and Oral Health Directorate Nursing Director Mary Wheeldon; and Brisbane North PHN CEO Libby Dunstan.

Dementia care in the North Brisbane and Moreton Bay region

A community that cares for dementia

The Brisbane North Dementia Care program engaged consumers, carers and health service providers in dementia awareness, education activities and a collaborative co-design process, which informs a regional strategy for living well with dementia.


A total of 71 GPs received training in dementia diagnosis, management and medication in primary care across three separate workshops.


The Redcliffe Aged Care Collaborative attracted 49 health professionals to three meetings; helping to improve collaboration and partnerships between acute, primary care and aged care providers in the Redcliffe region.

Improving the care journey for people living with chronic wounds

The PHN funds the delivery of evidence based chronic wound management education together with ongoing clinical mentoring support for staff working in residential aged care facilities and aged care community service providers.

112 people attended our workshops and online education sessions, with 84 clinical support appointments delivered this year. We also facilitate the Brisbane North Chronic Wound Governance Group—a group of providers working together to identify relevant and local needs, issues and solutions in chronic wound care.

Upskilling our palliative care workforce

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 a number of registered nurses to undertake either a Master of Nurse Practitioner or Graduate Certificate in Palliative Care.

We also supported the development of a palliative care community of practice to bring together a network of nurse leaders working in palliative care to enhance patient care through building connections and sharing knowledge.


Coordinated care for older people