Doutta Galla Community Health
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Mission Statement

Doutta Galla provides high quality, culturally appropriate and accessible primary, community and mental health services with a particular focus on the most vulnerable and disadvantaged in the cities of Melbourne and Moonee Valley.
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Doutta Galla Community Health Chronic Disease Strategy

Doutta Galla Community Health has taken on a system wide approach to chronic disease management. This has meant strengthening multidisciplinary teams to provide team based care, addition of Care Coordinators to these teams, allied health staff stepping into Key Liasion roles, training staff in health coaching, motivational interviewing techniques and strengthening assessment and care planning processes.

Wagner model


The World Health Organisation and the Department of Health endorse the Wagner Chronic Care Model.
Go to World Health Organisation website
Go to Department of Health Victoria website
This Model has influenced how Doutta Galla works with clients living with a chronic conditions. For more information:
Go to Improving Chronic Care website

DGCH plan, guidelines and pathways

Doutta Galla is focussing on the following key components of chronic care management:

Doutta Galla works collaboratively with staff across the organisation and with their clients to encourage them to better self-manage their health. Self-management is achieved by the client through:

  • Having a holistic assessment completed to determine what is important to them regarding their long term health condition(s); and
  • Engaging in the development of a goals based health plan.

The client is then supported to:

  • Follow their health plan.
  • Take a personal health folder to all health appointments. This lists important things about their health, such as medical history, medications and appointments.
  • Attending health appointments and engaging in treatment. They may need to see multiple health professionals to address their health needs.
  • Responding to reminders for repeat appointments.

How are clients assisted to achieve better health management?

A Care Coordinator will work closely with each client. Care Coordinators are health professionals who will:

  • Work with clients to develop their health plan.
  • Regularly meet with client to discuss their progress in better managing their long term health condition(s).
  • Liaise with all staff involved in the client’s care to ensure that they are kept informed of the client's progress.

How will clients benefit from using this service?

They will learn to take control of their health and get the most out of their life.

This is achieved by clients learning to:

  • Better understand and manage their long term health condition(s).
  • Feel more confident in making decisions with their health care team about their long term health condition(s).
  • Understand what helps them achieve a healthy lifestyle.
  • Gain knowledge of available supports in the management of their long term health condition(s).
  • Gain an understanding of behaviour changes which can be made.
  • The Care Coordinator will assist clients to gain a greater understanding of the self-management of their health condition.
  • By leading a healthier lifestyle they stay well for longer and minimise complications associated with their condition.
Client referrer

Eligibility

To be eligible you must have the presence of one or more of the following chronic disease condition(s):

  • Arthritis
  • Diabetes Type 2
  • Heart disease
  • Lung conditions such as asthma and chronic obstructive pulmonary disease(COPD)

Plus the client is interested in:

  • Support with behaviour/ lifestyle change, and/or
  • Self management support, and /or
  • Assistance with care coordination because multiple services are involved.

Information Brochures

Download Doutta Galla client brochure [PDF 428KB]
Download Doutta Galla referrer's brochure [PDF 436KB]

What can the client expect after submitting a referral?

  • Acknowledgement of receipt of referral.
  • When an appointment is arranged usually within 7 days of sending the referral- there is an indication during the first appointment.
  • Assessment results and planned intervention including details of the care plan and other referrals made.
  • Progress reports - triggered by a change in management and /or health status or a referral made to an additional provider.
  • Discharge report.

What is the cost?

  • No payment is required for the Care Coordinator however, normal fees are required for other health professionals
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