Integrated Team Care Program 2016–2022

Please note: this program has been recommissioned and renamed the ITC Enhanced Program as it now includes additional funding to support mental health.

The Integrated Team Care (ITC) program supports Aboriginal and Torres Strait Islander people with complex chronic diseases to effectively manage their conditions. It does this by providing access to one-on-one assistance from care coordinators and Aboriginal outreach workers.

The program assists people to quickly access culturally appropriate health services that align with their GP Management Plan for chronic disease management.

North Western Melbourne Primary Health Network’s commissioning process is designed to deliver targeted processes to meet local needs. ITC providers are tasked with developing and delivering flexible approaches to improve Aboriginal and Torres Strait Islander people’s access to the best possible care in their area.

Outreach workers and care coordinators are supported by Indigenous health project officers. The teams work with Aboriginal and Torres Strait Islander people across our region to assist them to obtain primary health care as required.

The objectives of the ITC program between 2016 and 2022 were to:

1. Contribute to better treatment and management of chronic conditions for Aboriginal and Torres Strait Islander people enrolled in the program.
2. Improve access to appropriate health care through care coordination and provision of supplementary services for eligible Aboriginal and Torres Strait Islander people with chronic disease.
3. Foster collaboration and support between the mainstream primary care and the Aboriginal and Torres Strait Islander health sector.
4. Improve the capacity of mainstream primary care services to deliver culturally appropriate services to Aboriginal and Torres Strait Islander people.
5. Increase the uptake of Aboriginal and Torres Strait Islander-specific Medicare Benefits Schedule (MBS) items, including Health Assessments for Aboriginal people and follow up items.

Overall outcomes associated with the delivery of ITC programs within the NWMPHN region included:

• Aboriginal and Torres Strait Islander people with chronic health conditions get access to the right care at the right time.
• Aboriginal and Torres Strait Islander people were actively supported to access specialist and allied health services.
• General practitioners were supported to provide culturally appropriate health services.
• Links between local health services and Aboriginal and Torres Strait Islander people were established and maintained.
• The cultural competency of mainstream providers was improved to reduce barriers for Aboriginal and Torres Strait Islander people to access services.
• Health service staff became more skilled through the delivery of relevant training, peer support and networking events.

Refer to the ITC Enhanced Program page for information on activities from 1 July 2022 to 30 June 2024.