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 to the ITC program for one-on-one care coordination to access the services they need to treat their chronic disease according to the General Practitioner care plan.
- Supplementary services refers to a flexible funding pool available to the care coordinator to assist patients to access urgent or essential health services (as well as certain associated medical aids). The funds can be used to improve access to specialist and allied health services in line with the patient’s care plan where services are not accessible through the public health system in a clinically acceptable timeframe, or where transport is inaccessible or unaffordable.
Who is eligible
- Aboriginal and/or Torres Strait Islander people who have a chronic condition, have a single GP Chronic Condition Management Plan
- 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 condition, have a single GP Chronic Condition Management Plan
- 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): 0447 235 794 (Mon - Fri)
- Bunurong Health Service (DDACL): (03) 7067 0384 (Mon - Thurs)
