Integrated Team Care Enhanced Program


1 July 2022 – 30 June 2024

Funding Amount:

ITC: $2,060,971 Psychosocial: $916,644



Melbourne Macedon Ranges Yarra Moonee Valley Darebin Maribyrnong Hobsons Bay Wyndham Brimbank Moorabool Melton Hume Merri-bek


The Integrated Team Care (ITC) program aims to support Aboriginal and Torres Strait Islander people with complex chronic health conditions to better manage their health. It connects patients with care coordinators, Aboriginal outreach workers, supplementary services and social supports.

The ITC program was initially commissioned from 2016 to 2022. It has now been recommissioned in an enhanced form until 2024.

The enhanced ITC program adds psychosocial funding to the program’s objectives, which are 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 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 and Torres Strait Islander people and follow up items.
  6. Provide non-clinical community-based supports aimed at improving social and emotional wellbeing for participants in the ITC program, their families, and their community.

NWMPHN added the sixth objective (highlighted in bold above) to its ITC program to provide clients with a holistic program that better supports their capacity to manage their chronic health conditions. This decision was made in consultation with providers and community members who said that supporting social and emotional wellbeing (SEWB) would positively affect clients’ physical and mental health and encourage connection with health providers.

To be eligible for the program, a client must:

  • identify as Aboriginal and/or Torres Strait Islander
  • have complex chronic health conditions
  • require care coordination or Aboriginal outreach to manage their chronic health conditions
  • be referred by a GP with an Aboriginal and Torres Strait Islander Peoples Health Assessment (MBS item 715) or a  Chronic Disease GP Management Plan (MBS item 721).

4 service providers have been recommissioned to implement the enhanced ITC program. They have delivered the ITC program for more than 6 years and hold strong connections with their clients and broader Aboriginal and Torres Strait Islander communities.


This program will contribute to improving health outcomes for Aboriginal and Torres Strait Islander people with chronic health conditions through:

  • care coordination, multidisciplinary care and support for self-management of conditions
  • improving access to culturally appropriate mainstream primary care services (including but not limited to general practice, allied health and medical specialists).

The program’s activities include (but are not limited to):

  • coordination of clinical and other care, purchasing medical aids, translating medical jargon, building health literacy and providing transportation.
  • Aboriginal outreach and advocacy at medical and other appointments
  • SEWB activities such as exercise and art groups, one-on-one sessions (counselling, check-ins) and cultural activities (excursions, yarning circles)
  • post-hospital or rehabilitation support
  • linking clients with appropriate primary, allied and community health care
  • connecting clients with housing, legal, food security and other services as needed

NWMPHN works with its service providers to ensure care is provided in a flexible, client-centred way that maximises engagement and positive outcomes for clients.


There is a centralised intake for referrals to the ITC program. Referrals must come from a GP. Referral forms can be downloaded below and faxed with a GP Care Plan to (03) 9348 0750.

Services involved