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:Â 3177, 3802, 3803, 3804, 3805, 3806, 3807, 3912, 3975, 3976, 3977, 3978, 3980, 3981
- Kingston:Â 3169, 3189, 3189, 3190, 3192, 3194, 3195, 3196, 3197, 3202
- Greater Dandenong:Â 3164, 3171, 3172, 3173, 3174, 3175, 3975
- Monash:Â 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.