
Social Work Service to Support GPs
For Patients with chronic or complex health care conditions
Description of Services
SNHN has commissioned two service providers, Primary and Community Care Services (PCCS) and Community Care Northern Beaches (CCNB) to provide a Social Work Service to Support GPs to assist in the prevention of hospital admission or re-admission for patient’s living with chronic or complex health care conditions. Social workers provide patients with appropriate service access to nutritional, social and welfare support.
PCCS Social Work Service to Support GPs
The PCCS GP Social Work Support Program adopts a patient-centred medical home approach to supporting the health, social and welfare needs of patients. The model works alongside a GP’s normal model of care and provides social work services to assist patients to improve their health and wellbeing, better navigate the system, access needed support, and avoid unnecessary hospitalisations. Social workers support GPs and their patients by facilitating and coordinating additional assistance with social, welfare and or community providers. This program runs in Hornsby, Ku-ring-gai and Ryde.
To learn more about the PCCS service CLICK HERE.
CCNB Community Care Northern Beaches
Access to timely and effective social work services enables people to stay Healthy at Home. CCNB delivers this model through the provision of a mobile team of experienced and qualified social workers who will work flexibly across the LGAs of Hunters Hill, Willoughby, Lane Cove, Mosman, North Sydney, and Northern Beaches.
To learn more about the CCNB Healthy at Home service CLICK HERE.



Eligibility
These services are for patient’s living with chronic or complex health care conditions.
How to refer
Referrals to these programs must be made by a GP.
For the CCNB GP Referral Form: CLICK HERE
For the PCCS GP Social Work Connect Referral Form CLICK HERE
Resources
- PCCS GP Social Work Connect Flyer
- PCCS GP Social Work Connect Referral Form
- CCNB GP Referral Form
- CCNB Flyer for GPs
- CCNB Social Work Medical Direction Template (right-click and “Save as…”)
- SNHN instructions on importing templates into Medical Director.
- CCNB Social Work Best Practice Template (right-click and “Save as…”)
- SNHN instructions on importing templates into Best Practice.
