Integrated Team Care Program

Provides Aboriginal and Torres Strait Islander patients who have one or more chronic condition with a dedicated care coordinator to work closely with them and their care team, as part of ongoing care.

Eligibility criteria - For Aboriginal and Torres Strait Islander people with:

with one or more chronic conditions

are of any age, including children with early onset of chronic conditions

a current GPMP with or without TCA

are at risk of hospital admission due to their ill health

have trouble accessing and using the right services for their care

have trouble managing multiple services and appointments.

Referrals

Referrals can be sent to the preferred provider in your area:

Wollongong

Illawarra Aboriginal Medical Service

Grand Pacific Health

Nowra

Grand Pacific Health

South Coast Medical Service Aboriginal Corporation

Waminda – South Coast Women’s Health and Wellbeing Aboriginal Corporation

A GP Management Plan (GPMP) is required to access ITC. For referrals to a local AMS please ensure the GPMP is not completed at your practice. The AMS will complete the GPMP and enrol your patient into ITC. If the GPMP is completed at your practice the patient will not be able to access ITC via the AMS.

For referrals to GPH, please complete the referral form and send to the Intake Coordinator along with a Aboriginal and Torres Strait Islander Health Assessment (MBS 715) and GPMP. Ensure to include the care coordinator as part of the GPMP/TCA.

Visit HealthPathways for further detailed information.