Indigenous Australians’ Health Program – Integrated Team Care


$1 million per annum

Funding Amount

July 2016 to 30 June 2022


North West Catchment



The Integrated Team Care (ITC) program supports Aboriginal and Torres Strait Islander people with complex chronic diseases to effectively manage their conditions, through access to one-on-one assistance by care coordinators.

The program aims to assist people to access health services as soon as possible and ensure they have adequate supports to get the care required in a culturally safe way.

ITC providers seek to develop and deliver flexible approaches to improve Aboriginal people’s access to high quality, culturally appropriate health care. It is designed to deliver approaches that best meet local needs through the commissioning process.

ITC is provided by teams of Indigenous health project officers, Aboriginal outreach workers and care coordinators. The teams work across our Primary Health Network region to assist Aboriginal people to obtain primary health care as required.

The objectives of the ITC program are to:

  1. Contribute to better treatment and management of chronic conditions for Aboriginal people enrolled on the program.
  2. Improve access to appropriate health care through care coordination and provision of supplementary services for eligible Aboriginal people with chronic disease.
  3. Foster collaboration and support between the mainstream primary care and the Aboriginal health sector.
  4. Improve the capacity of mainstream primary care services to deliver culturally appropriate services to Aboriginal 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 expected outcomes associated with the delivery of ITC programs include:

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


There is a centralised intake for referrals to the ITC program. Referral forms can be downloaded below.

Services involved

Reconciliation Action Plan

North Western Melbourne Primary Health Network (NWMPHN) has focused on engaging and supporting the Aboriginal and Torres Strait Islander community since inception.