Chronic diseases are major contributors to the mortality gap between Aboriginal and Torres Strait Islander and other Australians. The Australian Government has committed to closing the gap that exists between Indigenous and non-Indigenous Australians across health, education and employment.
Commissioned by SEMPHN, the Integrated Team Care Program (ITC) was established to support Aboriginal and Torres Strait Islander people with complex chronic diseases who experience challenges with effectively managing their conditions. It is provided by a team of Indigenous health project officers, Aboriginal and Torres Strait Islander outreach workers and care coordinators.
ITC has two main components:
- Care coordination is provided by a qualified healthcare worker to Aboriginal and Torres Strait Islander people with a chronic disease. Patients are referred by their GP from a general practice participating in the Practice Incentives Program (PIP) Indigenous Health Incentive.
- Supplementary services refers to a flexible funding pool available to the care coordinator to assist patients to access urgent or essential health services. The funds can be used to improve access to specialist and allied health services in line with the patient’s care plan.
Who is eligible
- Aboriginal and/or Torres Strait Islander people who have a chronic disease, have a current GP Management plan (GPMP) and Team Care Arrangements (TCA)
- Those living in Bayside, Cardinia, Casey, Frankston, Glen Eira, Greater Dandenong, Kingston, Mornington Peninsula, Port Phillip, or Stonnington LGAs.
As a guide, patients most likely to benefit from the service include:
- Patients who are at greatest risk of experiencing otherwise avoidable (lengthy and/or frequent) hospital admissions;
- Patients at risk of inappropriate use of services, such as hospital emergency presentations;
- Patients not using community based services appropriately or at all;
- Patients who need help to overcome barriers to access services
- Patients who require more intensive care coordination than is currently able to be provided by General Practice or Aboriginal Health Service staff;
- Patients who are unable to manage a mix of multiple community-based services
SEMPHN commissions Better Health Network (BHN) and the Dandenong and District Aborigines Co-operative Limited (DDACL) to develop, implement and administer the ITC program.
- Aboriginal and/or Torres Strait Islander people who have a chronic disease, have a current GP Management plan (GPMP) and Team Care Arrangements (TCA)
- Those living in Bayside, Cardinia, Casey, Frankston, Glen Eira, Greater Dandenong, Kingston, Mornington Peninsula, Port Phillip, or Stonnington LGAs.
As a guide, patients most likely to benefit from the service include:
- Patients who are at greatest risk of experiencing otherwise avoidable (lengthy and/or frequent) hospital admissions;
- Patients at risk of inappropriate use of services, such as hospital emergency presentations;
- Patients not using community based services appropriately or at all;
- Patients who need help to overcome barriers to access services
- Patients who require more intensive care coordination than is currently able to be provided by General Practice or Aboriginal Health Service staff;
- Patients who are unable to manage a mix of multiple community-based services
SEMPHN commissions Better Health Network (BHN) and the Dandenong and District Aborigines Co-operative Limited (DDACL) to develop, implement and administer the ITC program.
How to refer
Ask for an ITC Care Coordinator at
- Better Health Network (BHN): 132 246
- Bunurong Health Service (DDACL): 03 8902 9700
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SEMPHN acknowledges the Bunurong and Wurundjeri peoples of the Kulin Nation, the Traditional Owners and Custodians of the lands, waters, and skies in which we work. We pay our respects to their Elders past and present. We also acknowledge all First Nations peoples with whom we work. Sovereignty was never ceded!