Current projects in the Service Coordination Chronic Disease Management space;

  • Health literacy

  • S2S (Service to Service Referral)

  • Care Pathways

  • Service Coordination Survey

  • ACIC (Assessment Chronic Illness Care) PACIC (Patient Audit of Chronic Illness Care)

  • Bass Coast Youth Assist Clinic - YAC

Please refer below for further information on the above projects

Health Literacy

Health Literacy is the degree to which a person has the capacity to obtain, communicate, process and understand health information and services to make appropriate health decisions.

Health Literacy is important as it shapes peoples long-term health outcomes and the safety and quality of the care they receive.

The infrastructure, policies, processes, materials, people and relationships that make up the health system have an impact on the way in which people are able to access, understand, evaluate and apply health-related information and services.

Gippsland Guide to becoming a Health Literate Organisation

The Gippsland Primary Care Partnership have created the Gippsland Guide to becoming a Health Literate Organisation. The Guide has been developed specifically to align with the accreditation standards of Gippsland Health Services.

This Guide provides tools and resources to support your organisation to become more health literate. Organisational health literacy will result in improved health outcomes for your clients.

How the PCP can support your organisation

The Primary Care Partnership role is to work with champions within member organisations to help them to drive activities to improve Organisational Health Literacy within their workplace.

  • Identify agency champions
  • Support agencies to measure current organisational practice using the self-assessment checklist in the guide
  • From the results of the self-assessment checklist the PCP will support agencies to create a 1 year quality improvement action plan mentor agency champions to help them implement the action plan within their workplace
  • After 12 months of implementation, work with agency champions to use the self-assessment to measure the progress improvements that have occurred in the past year
  • Create a new 1 year action plan and the improvement cycle starts again

S2S (Service to Service Referral)

Service-to-Service (S2S) applications are designed to promote inter-agency communication, making it simpler to effectively coordinate client care. However, the benefits of S2S go beyond service coordination. S2S facilitates the sharing of information (with appropriate client consent), building a client history that extends beyond a single service or agency. This supports health and community workers to make better informed decisions about client care. S2S also supports record management principles, which are a key driver in increasing organisational efficiency. S2S applications ensure that the right information is at the fingertips of the workforce when they need it, this saves on time spent looking for information and unnecessary duplication.

Key Benefits

  • Better communication and collaboration
  • Facilitates improved client care
  • Streamline administrative processes

Care Pathways

Please find below Care Pathways for South Coast;

Chronic Obstructive Pulmonary Disease

  • South Gippsland Care Pathway - Chronic Obstructive Pulmonary Disease (Gippsland Southern Health Service)
  • South Gippsland Care Pathway - Chronic Obstructive Pulmonary Disease (South Gippsland Hospital)
  • Bass Coast Care Pathway - Chronic Obstructive Pulmonary Disease (Bass Coast Health)

Ongoing Stroke Care Management (after rehabilitation phase)

  • Bass Coast Care Pathway - Ongoing Stroke Care Management (Bass Coast Health)
  • South Gippsland Care Pathway - Ongoing Stroke Care Management (Gippsland Southen Health Service)
  • South Gippsland Care Pathway - Ongoing Stroke Care Management (South Gippsland Hospital)

Type 2 Diabetes - Annual Cycle of Care

  • Bass Coast Health - Type 2 Diabetes
  • Gippsland Southern Health Service - Type 2 Diabetes
  • South Gippsland Hospital - Type 2 Diabetes

Service Coordination Survey

The Service Coordination survey;

  • allows organisations to track their own progress in service coordination practice and to view it in comparison to that of other agencies
  • provides information to PCP’s to enable them to focus their efforts to support organisations in their area
  • provides information to the department about the results of its strategies to support system change in service coordination across Victoria.

The system and practice areas measured include;

  • eHealth
  • shared care/case planning
  • communication with general practice
  • initial needs identification
  • referral

This findings from the survey may be used by organisations for quality improvement processes, accreditation reporting and Quality of Care Reports.

Assessment Chronic Illness Care (ACIC)

The ACIC is a tool to enable service to self evaluate chronic disease programs. It comprises of 34 questions divided into 7 sections, 1 section for each of the 6 Wagner elements and the 7th to assess the integration of these elements.

Please refer to attached sheet - Tips for conducting ACIC and PACIC

Patient Audit of Chronic Illness Care (PACIC)

The PACIC is an audit of patient experiences of the health system. It can be used by health services to improve chronic illness care. The survey has 20 questions for the patient to answer, either following a specific service or as part of a consultation. Organisations need to gain consent from patients to participate in the PACIC.

Please refer to attached sheet - Tips for conducting ACIC and PACIC

South Coast Youth Clinic Partnership


The purpose of the South Coast Youth Clinic Partnership is to provide a regular forum for all youth clinics across Bass Coast and South Gippsland (South Coast catchment) to meet to discuss and develop strategic directions and business planning to achieve best practice health outcomes for young people.

The 4 clinics include;

  • Bass Coast Youth Assist Clinic (Wonthaggi Medical Group and Bass Coast Health)
  • Foster Youth Assist Clinic (South Gippsland Hospital and Foster and Toora Medical Centre)
  • Leongatha Youth Access Clinic (Leongatha Healthcare)
  • Korumburra Youth Access Clinic (Korumburra Medical Centre and Korumburra Secondary College)

The vision of the partnership is to ‘Support youth health & well-being’ in the South Coast. Therefore staying true to this vision all decisions will be made with a person centered approach in mind, considering first and foremost how to provide the best health specific health service for the young people across the South Coast catchment.

For any further information on the South Coast Youth Clinic Partnership please contact the PCP

Bass Coast Youth Assist Clinic - YAC

WHAT - a safe and confidential health clinic for young people aged 12-25 years

HOW - No appointment necessary, JUST DROP IN

WHERE - Wonthaggi Medical Group (Biggs Drive entry, first door opposite the bus stop

WHEN - Open every Tuesday (excluding school holidays)

General Medical - Access to a GP or nurse for all health issues such as colds, skin conditions, aches and pains

Sexual Health

  • Pregnancy testing available
  • Emergency contraception and contraception option
  • Promotion of safer sex
  • Testing of sexually transmissible diseases
  • Information or referral regarding sexual assault
  • Period concerns, managing painful, irregular or heavy periods

Drugs and Alcohol - Counselling, advice and information

Mental and Emotional Well-being - Counselling for all mental health issues, including;

  • Anxiety
  • Depression
  • Eating Disorders
  • Self Harm
  • Bullying
  • Suicide Prevention
  • Coping with family break-up

Please follow the Bass Coast YAC on facebook on the below link