Integrated Team Care (ITC)

The aims of the Integrated Team Care program are to contribute to improving health outcomes for Aboriginal and Torres Strait Islander people with chronic health conditions through better access to coordinated and multidisciplinary care; and to closing the gap in life expectancy by improved access to culturally appropriate mainstream primary care services (including but not limited to general practice, allied health and specialists) for Aboriginal and Torres Strait Islander people.

The objectives are to:

  • Achieve better treatment and management of chronic conditions for Aboriginal and Torres Strait Islander people, through better access to the required services and better care coordination and provision of supplementary services
  • Foster collaboration and support between the mainstream primary care and the Aboriginal and Torres Strait Islander health sectors
  • Improve the capacity of mainstream primary care services to deliver culturally appropriate services to Aboriginal and Torres Strait Islander people
  • Increase the uptake of Aboriginal and Torres Strait Islander specific Medicare Benefits Schedule (MBS) items, including health assessments for Aboriginal and Torres Strait Islander people and follow up items
  • Support mainstream primary care services to encourage Aboriginal and Torres Strait Islander people to self-identify
  • Increase awareness and understanding of measures relevant to mainstream primary care

At Boab Health Services, ITC is provided by a team of care coordinators, an Indigenous Health Project Officer (IHPO) and an Aboriginal Outreach Worker. The team works  across the indigenous and mainstream primary care sectors, to assist Aboriginal and Torres Strait Islander people to obtain primary health care as required, provide care coordination services to eligible Aboriginal and Torres Strait Islander people with chronic disease/s who require coordinated, multidisciplinary care, and improve access for Aboriginal and Torres Strait Islander people to culturally appropriate mainstream primary care.

The team works in the following ways:

Care Coordination and Supplementary Services Program.

The program helps to improve health outcomes for Aboriginal people suffering a chronic disease through assisted coordinated care and improved access to services that may have been beyond an individual’s means.

For example through the CCSS program our Care Coordinators can assist Aboriginal clients with chronic disease by:

  • Providing education on the client’s chronic disease and promoting self-management to adhere to medication and treatment regimes.
  • Arranging appointments for diagnostic tests, allied health professionals, or specialists
  • Connecting  with other community based services
  • Providing transport support to attend appointments
  • Enabling access to private specialists/health professionals if public is not available
  • Providing financial assistance with approved medical aids such as assisted breathing equipment, podiatry approved shoes, dose administration aids and blood sugar monitoring equipment

 Patient Eligibility:

To be eligible for care coordination under the CCSS program patients must:

  • Identify as being of ATSI descent
  • Have a chronic disease
  • Have a current GP Management Plan and/or Team Care Arrangement
  • Be referred to the program by their general practitioner

Patient Referral

GPs should complete a Closing the Gap – Integrated Team Care Referral Form and a GP Management Plan and send to Boab Health Services. Referrals can be sent by MMEX, fax or mail.

Patients most likely to benefit from this service include those who are: 

  • At great risk of experiencing otherwise avoidable frequent/ lengthy hospital visits
  • At risk of inappropriate use of services, such as hospital emergency presentations
  • Not using community based services appropriately or at all
  • Experiencing barriers to accessing services
  • Requiring more intensive care coordination than the general practitioner is able to provide
  • Unable to manage a mix of multiple community based services

Aboriginal Outreach Worker (Broome)

The ITC team also includes an Aboriginal Outreach worker based in Broome. The Aboriginal Outreach worker can provide practical assistance to identified Indigenous Australians to access mainstream primary health care including:

  • Encouragement to self-identify, assistance to attend health checks and health related appointments, Medicare registration, paper work, follow-up care and medication and prescription collection
  • Advocacy and support as appropriate during visits to GPs, specialists and allied health professionals
  • Distributing information/resources to local Indigenous communities about available services
  • Identifying and communicating barriers that may impact on access to health services by Indigenous people
  • Providing transport to other health services if this is not already provided within the other service.

Indigenous Health Project Officer

Our Indigenous Health Project Officer and ITC team leader supports the care coordinators and outreach worker, as well as providing a focus on indigenous health issues at the local level. Responsibilities include the development and implementation of strategies to:

  • Improve access to mainstream primary care for ATSI people
  • Increase uptake of Indigenous specific MBS items including Indigenous health checks and follow up items
  • Assist with self-identification of Indigenous Australians to mainstream primary care services
  • Improve the capacity of mainstream primary care providers to deliver culturally sensitive primary care services to ATSI people
  • Increase awareness and understanding of relevant Closing the Gap measures