About the program

The Integrated Team Care program supports Aboriginal and Torres Strait Islander people with chronic conditions to access the health care they need.

This program is funded under the Indigenous Australians’ Health Programme.

Why it is important

Almost half of Aboriginal and Torres Strait Islander people live with at least one chronic condition.

Heart disease and diabetes are the 2 leading causes of death for Aboriginal and Torres Strait Islander people.

Chronic conditions require complex health care across various types of health services. This program provides support to help patients understand and manage their conditions.

Goals

The program aims to:

  • better treat and manage chronic conditions among Aboriginal and Torres Strait Islander people
  • improve the health of Aboriginal and Torres Strait Islander people with chronic health conditions
  • improve access to culturally appropriate mainstream primary health care services
  • foster collaboration and support between the mainstream and Aboriginal and Torres Strait Islander health sector.

Meeting our goals

The program funds Primary Health Networks (PHNs) to engage health organisations, which provide individual support to clients of the program by:

  • making sure clients can access the right care when they need it, including specialist and allied health care
  • linking health care across various services
  • ensuring quicker access to health services
  • setting clear care pathways
  • helping mainstream health services provide culturally appropriate care.

The program funds teams of:

  • Aboriginal and Torres Strait Islander health project officers
  • Aboriginal and Torres Strait Islander outreach workers
  • care coordinators.

Aboriginal and Torres Strait Islander health project officers

Aboriginal and Torres Strait Islander health project officers are the team leaders for their region. They:

  • coordinate and support the outreach workers and care coordinators in their region
  • build capacity of health services in their region to deliver culturally appropriate care
  • support different types of health services across their region to communicate and work together.

Aboriginal and Torres Strait Islander outreach workers

Outreach workers have strong links to their community, and help their clients with non-clinical tasks, such as:

  • providing information about what services are available and where they are
  • encouraging clients to access health care and collect medication
  • organising transport to and from medical appointments.

Care coordinators

Care coordinators are qualified health workers, such as nurses or Aboriginal and Torres Strait Islander health workers. They:

  • arrange the services in clients’ general practitioner (GP) care plans
  • organise regular reviews by the primary care providers
  • provide clinical care
  • speed up access to urgent and essential allied health or specialist services
  • help clients access some GP-approved medical aids
  • help clients better manage and understand their condition.

Who we work with

We fund the PHNs to manage the program. They work with the Aboriginal and Torres Strait Islander health sector and mainstream health services.

The PHNs can develop flexible approaches that meet the needs of Aboriginal and Torres Strait Islander people with chronic conditions in their regions. 

Learn more

Integrated Team Care Program implementation guidelines

This document outlines how the Integrated Team Care Program works, and how funded organisations should implement and manage funded activities.

Contact

For more information, contact the Primary Health Network in your area.

Last updated: 
30 June 2021