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Community Care Social Work provides targeted, brief psychosocial interventions that enable people to remain safely in the community, prevent avoidable hospital admissions and readmissions, and support timely discharge from hospital. The service addresses psychosocial factors that influence health, recovery, independence, and participation, supporting people to achieve safe and sustainable outcomes in the community.

About this service

We are an appointment based Social Work Service; we do not provide a crisis service or case management support.

We can assist you with:

  • Providing targeted, time-limited intervention for psychosocial issues associated with a person's current health condition or episode of care. Psychosocial issues that are unrelated to health, recovery, discharge, or community functioning may be more appropriately addressed by other specialist services.
  • Providing clinical psychosocial assessments to understand how a person’s psychological, social and environmental factors interact to affect their health, functioning and treatment needs, enabling social workers to create an individual goal-based care plan.
  • Providing continuity of social work support across the hospital-to-community pathway to facilitate timely discharge, reduce the risk of readmission, and support recovery in the community.
  • Providing brief counselling and psychosocial support for health-related distress, including mild to moderate reactive anxiety and depression.
  • Providing short-term grief and loss support related to declining health, health-related bereavement, and the death of a partner or significant support person.
  • Providing support for partners and carers of eligible adults where caring responsibilities are impacted by the person's health condition or psychosocial circumstances.
  • Supporting to adjust to a recent diagnosis, significant change in health status, or the impact of chronic and complex health condition.
  • Addressing psychosocial factors that impact recovery, independence, community participation, and quality of life.
  • Supporting self-management, promoting resilience and empowerment to enhance long-term health and wellbeing outcomes.
  • Facilitating access and referrals to practical, emotional, financial, housing and community supports that assist people to remain safely in the community and reduce the risk of avoidable hospital admissions.
  • Support to navigate complex health, aged care and community service systems and make informed decisions about your care and support needs.
  • Support to make informed decisions about your care, balancing individual choice and dignity of risk with strategies to identify, manage and minimise psychosocial risks, and promote safe and sustainable outcomes in the community.

Who we care for

Our service is for ACT residents who are not receiving Counselling or Social Work elsewhere.

Adults who present with one of the following health related conditions:

  • Bereavement Support (passing days/weeks to months/years ago)
  • Death of a carer, where there is no other support
  • Recent significant change in a health condition/s causing distress or adjustment issues
  • Chronic or acute illness causing mild/moderate depression or anxiety, self-care problems, social isolation, family or relationship stress
  • Chronic conditions self-management, including support to prevent hospital admissions and/or to improve managing self-care/coping with the chronic condition
  • After discharge from hospital with post-acute illness issues resulting in concerns with home care, stress isolation or depression.

How to access this service

You can make an appointment by calling Central Health Intake on (02) 5124 9977.

With your consent, referrals can also be made by:

  • individuals - you or your family members
  • your GP, medical specialists or other health professionals
  • other community agencies and services in the ACT region.

What to expect

Central Health Intake (CHI) will make your first appointment with the relevant social worker when they receive your referral.

Where we're located