The ITC Program is a short-term program to: Support Aboriginal and Torres Strait Islander people with complex chronic care needs to improve self-management of their condition; support access to clinically necessary medical equipment and/or services that would otherwise be inaccessible in a clinically appropriate timeframe; and/or to provide care coordination.1
Referring GP Details: (stamp accepted)	

Name: 	

Practice:	

Practice Address: 	

Phone: 	
Fax: 	

Patient Details:	
First Name: 	Date of Birth: 	
Surname: 	Phone:
Phone 	
Residential Address: 
	Postcode: 	
Next of Kin/Alternate Contact:	Alternate Contact Phone	
    My patient fulfils ALL the criteria below:    
	 Is Aboriginal, or Torres Strait Islander, or Aboriginal and Torres Strait Islander	
	 Has chronic and complex health needs and requires multidisciplinary care	
	 Has a care plan/GP Management Plan. Attach patient care plan with referral	
	 Has given verbal or written consent to be contacted by the ITC team to discuss participation in the ITC Program	
Chronic Disease Details  (Tick ALL applicable to patient)	
	
Diabetes	
	
Eye health condition associated with diabete	

Cardiovascular disease	
	
Chronic kidney disease	

Cancer	
	
Chronic respiratory disease	

Other4 – specify:	

	
Is another organisation already currently providing Care Coordination? If yes, specify:
       …………………………………………………………………………………………………………………………………………………………………………………………
Eg. Aboriginal Community Controlled Health Service; ICDC Program. Provide Client ID Number if available.	

       Reason/s for ITC Referral:        
	Requires Supplementary Services support		Current ITC client moving to new ITC Provider region	
	Requires Care Coordination support		Patient has exhausted Medicare CDM Allied Health visits	
   
Provide brief detail as per care plan:
       ………………………………………………………………………………………………………………………………………………………………………………………..
       …………………………………………………………………………………………………………………………………………………………………………………….….
Eg. Ulcerated foot. Request Medicare Gap payment support for 2 x Podiatrist services. Upcoming appointment 18/4/18.	
THE ITC PROGRAM IS ONLY ABLE TO PROVIDE SUPPORT AS OUTLINED IN GP CARE PLAN
See over page for examples of potential ITC support, and include ALL relevant needs in care plan
Patient Information and Consent	
My GP has explained the purpose of this referral for the ITC Program; I give permission for my care plan to be shared with the Care Coordinator; I give permission for the Care Coordinator to contact me to discuss how the ITC Program can support me in my care plan needs.	
Patient signature:	
Date:	

GP signature:5	
Date:	

Forward completed ITC Referral Form AND GP care plan AND other relevant documents to ITC Provider
 1See ITC HealthPathways for further information – https://wa.healthpathways.org.au/65938.htm?zoom_highlight=integrated+team+care++itc,  (username: connected; password: healthcare).
2Multidisciplinary care is not an eligibility requirement to access the Program, however priority will be given to those meeting all check box criteria
3Where written consent has not been provided at point of referral it must be provided at point of registration before ANY ITC support can occur
4To be consistent with the MBS, an eligible condition is one that has been, or is likely to be, present for at least six months 
5Remote Area Nurse may refer when a GP will not be available in remote area in a clinically appropriate timeframe
Requested Care Coordination Support could include:	
Help client arrange appointments for chronic condition management	Eg. GPMP Reviews with usual GP, diagnostic tests, pharmacy review, allied health and specialist visits.
Forward required copy of GP Care Plan with WA ITC Referral Form

Where possible also forward other supporting documents relevant to chronic condition management and ITC support needs. For example:
•	Upcoming appointment dates;
•	Team Care Arrangements; Allied Health Medicare CDM Referral Form
•	Medicare Referral Form for follow-up allied health services for Aboriginal or Torres Strait Islander people
•	Copy of named/preferred provider referral form	
Clinical service	Eg. Clinical observations (BMI, BP, etc), health promotion, contribute to care planning, condition monitoring, self-management support.	
Case Conferencing/Management	Eg. Support practice staff to arrange case conferencing; participate in case conferencing and team care.	
Attend initial appointments with client	Eg. Support client to become comfortable in new clinical setting, overcome language barriers, understand clinical language; provide cultural brokerage.	
Provide client education on chronic condition/s and care plan	Eg. Medication, treatment regimen	
Link client with general wellbeing and holistic care support	Eg. Women’s/men’s support groups, social and emotional wellbeing support, cultural healing.	
Arrange transport for access to chronic condition management appointments	Where the client doesn’t already have access to alternative transport.	

Requested Supplementary Services Support could include:	
Provide financial assistance to enable access to approved medical equipment	Eg. Approved aids include: Assisted breathing equipment, blood sugar/glucose monitoring equipment, dose administration aids, medical footwear as prescribed and fitted by podiatrist, mobility aids, spectacles. Note: Requests for CPAP require Sleep Study and trial of CPAP before ITC support to access CPAP can be considered.	
Provide financial assistance to enable access to specialist/allied health professional services	Where it has been indicated that patient is financially unable to access clinically necessary services for the management of their chronic condition; and/or patient has exhausted available Medicare Allied Health items.	
Provide transport for access to chronic condition management appointments	Where the client doesn’t already have access to alternative transport.	
APPROVAL OF THE SUPPORT REQUESTED WILL BE ON A PRIORITY BASIS AND CONTINGENT ON
STAFF CAPACITY AND AVAILABLE FUNDING

FORWARD REFERRAL TO APPROPRIATE ITC PROVIDER
ITC Providers will forward referrals received for clients of other ITC regions to the correct ITC Provider	
Perth Metro – North West, South East, Inner Metro – 
Arche Health – Ph 9458 0505; Fax 9458 8733; SMD  MMEx	Midwest - North – Carnarvon Medical Service Aboriginal Corporation – Ph 9941 2499; Fax 9941 2024	
Perth Metro – North East, South West – 
Moorditj Koort – Ph 6174 7000; Fax 9439 6288; SMD MMEx	Midwest - South – Geraldton Regional Aboriginal Medical Service (GRAMS) – Ph 9956 6555; Fax 9964 3225	
Perth Metro – South West –
Nidjalla Waangan Mia; Ph 9586 4580; Fax 9583 5495;
SMD HealthLink	South West – Down South Aboriginal Health, Manjimup: 
Ph 9771 2260, Fax 9771 2259; South West Aboriginal Medical Service (SWAMS), Bunbury: Ph 9726 6000, Fax 9752 4835	
Great Southern – Amity Health –
Ph 9842 2797; Fax 9842 2798	Wheatbelt – Coastal, Eastern, Western Wheatbelt – 
Wheatbelt Health Network – Ph 9621 4444; Fax 9621 2119;
SMD HealthLink	
Pilbara – Mawarnkarra Health Service (MHS) –  Ph 9182 0851;
Fax 9182 0851	Wheatbelt – Southern Wheatbelt – Amity Health –
Ph 9842 2797; Fax 9842 2798; SMD MMEx	
Goldfields – Hope Community Services – 
Ph 9497 9498; Fax 9091 8920	Kimberley - Boab Health Services – Broome: Ph 9192 7888; Kununurra: Ph 9168 2560; Fax 9192 7999; SMD MMEx