Complex Biopsychosocial Needs – Adult

The Complex Biopsychosocial (Care in Context) Team works in partnership with GPs and other health providers to support their clients in the community. The service provides a comprehensive approach to assisting people in self-managing their chronic disease and/or complex psychosocial issues. Clients are supported short-term and then discharged with support from GPs.

• self-management education
• facilitating access to short-term responsive care coordination
• psychosocial needs assessments and referral to allied health or psychologist as appropriate
• medication review, understanding and adherence, and where appropriate a referral to HOMR is completed
• coordinating the communication and care of the client with health and service providers
• facilitating greater cohesion and linkage across acute settings, community service and specialist care
• review at Chronic Disease Management Clinic if appropriate

Eligibility Criteria

This service is for clients who:

• are over 18 years old and reside in the Monash Health catchment
• Emergency Department presentation or admission within the last 6 months
• are at high risk of presenting at hospital
• have a chronic condition which can be improved through education and support around self-management

This service is not for clients:

• whose primary condition is renal failure on dialysis, eGFR is <15%
• whose primary condition is mental health, alcohol or drug dependence
• whose condition is being managed by Workcover or TAC
• whose primary condition is cancer
• who are receiving palliative care
• who are pregnant or post-partum

Referral Method(s)

Referrals should be sent by eReferral through Healthlink or by email.

Phone:  03 8572 5631
Email:  icareaccess@monashhealth.org

Eligible Postcodes

• Cardinia:3781, 3782, 3783, 3807, 3808, 3809, 3810, 3812, 3813, 3814, 3815, 3981, 3981, 3984
• Casey: 3177, 3802, 3803, 3804, 3805, 3806, 3807, 3912, 3975, 3976, 3977, 3978, 3980, 3981
• Kingston: 3169, 3189, 3189, 3190, 3192, 3194, 3195, 3196, 3197, 3202
• Greater Dandenong: 3164, 3171, 3172, 3173, 3174, 3175, 3975
• Monash: 3125, 3147, 3148, 3149, 3150, 3164, 3166, 3167, 3168, 3170, 3800

Additional information required

Include all patient demographic and clinical details as well as relevant investigation results.

Contact hours: 8.30am – 4.30pm, Monday to Friday (except public holidays)

Click here for more information about this service.

Please review the eligibility criteria before submitting a referral.