Integrated Team Care

The Integrated Team Care (ITC) program aims to contribute to improving health outcomes for Aboriginal and Torres Strait Islander people with chronic health conditions through better access to care.

Eligible patients

• Identify as an Aboriginal and/or Torres Strait Islander person
• Have a chronic condition diagnosis including but not limited to diabetes, cancer, cardiovascular disease, chronic kidney disease, chronic respiratory disease or a mental health condition
• Have a current GP Management Plan or Team Care Arrangement
• Living in the Goulburn, Murrindindi and Mitchell shire areas.

Referrals

GPs must refer their patients to the ITC Care Coordinator using the ITC referral form. Please attach the GPMP or TCA outlining the patient’s health care needs.

Closing the Gap

The ITC program is available at no cost to all Aboriginal and Torres Strait Islander people living in the Goulburn, Murrindindi and Mitchell shire areas, regardless of which GP clinic or health service they use.

Care Coordinator

A Care Coordinator is a qualified health professional who can support a patient to manage their complex health needs. Care Coordinators can assist with access to a range of services, including appointments with specialists and allied health professionals, arrangements for home help and making connections with support groups. They can also access medical aids for the patient’s chronic condition.

Outreach Worker

An Outreach Worker can assist a patient to travel to and from medical appointments as needed, including follow-up care and visits to the pharmacy. They can also provide patients and their families with information, resources and advocacy in regards to culturally-appropriate services available in the local community.

Indigenous Health Project Officer

An Indigenous Health Project Officer can work with GP clinics, Aboriginal health services and mainstream health services to improve their capacity to deliver culturally-appropriate health care to Aboriginal and Torres Strait Islander people. This support may include the provision of resources and training as appropriate.

This activity is funded by Murray PHN through the Australian Government’s PHN Program.