Integrated Team Care Update

NCPHN is pleased to announce the appointment of new service providers for Integrated Team Care.

What is Integrated Team Care?

The Integrated Team Care (ITC) Activity combines the former Care Coordination and Supplementary Services (CCSS) and Improving Indigenous Access to Mainstream Primary Care (IIAMPC) programs. Funds for the ITC Activity are managed by Primary Health Networks. ITC aims to:

• Contribute to improving health outcomes for Aboriginal and Torres Strait Islander people with chronic health conditions through better access to coordinated and multidisciplinary care.
• Contribute to closing the gap in life expectancy by improved access to culturally appropriate mainstream primary care services (including but not limited to general practice, allied health and specialists) for Aboriginal and Torres Strait Islander people.

Integrated Team Care is provided by a team of Indigenous Health Project Officers (IHPOs), Aboriginal Outreach Workers (AOWs) and Care Coordinators.

The team works in the NCPHN region, across the Indigenous and mainstream primary care sectors to:

• assist Aboriginal and Torres Strait Islander people to obtain primary health care as required.
• provide care coordination services to eligible Aboriginal and Torres Strait Islander people with chronic disease/s; and
• improve access for Aboriginal and Torres Strait Islander people to culturally appropriate mainstream primary care.

Care Coordination

The Care Coordination and Supplementary Services (CCSS) program aims to improve the health and wellbeing of Aboriginal and/or Torres Strait Islander people with a chronic health condition.

Care Coordination means working collaboratively with patients, general practices, AMSs and other service providers to assist with the care coordination of eligible patients.

A Care Coordinator can:

• Assist Aboriginal and Torres Strait Islander people to understand their chronic health condition and how to manage it.
• Assist Aboriginal and Torres Strait Islander people to follow their care plan, which many include support for chronic disease self-management and assistance with care plan compliance.
• Access a supplementary services funding pool to assist patients to access medical specialist and allied health services, medical aids and transport.

Who can access Care Coordination?

Aboriginal and Torres Strait Islander people who have a chronic health condition. A chronic disease is an illness that has been or is likely to be present for at least 6 months.

Patients will also require:

• A current GP management plan
• Written referral from their GP

For further details about accessing this program, please contact your local Care Coordination provider. Contact details can be found below under ‘Commissioning of Integrated Team Care’.

Aboriginal Outreach Worker Program

Aboriginal Outreach Workers help local Aboriginal and Torres Strait Islander people make better use of available health care services, especially mainstream health services.

An Aboriginal Outreach Worker can:

• Provide support with ongoing follow-up by health providers.
• Promote effective communication between health care providers and patients.
• Assist clients with travel to and from appointments.
• Where required, accompany patients to appointments to improve understanding between health care provider and patient.
• Advocate on clients behalf at the doctors or specialist.
• Distribute information about services available to the Aboriginal community and how to access them.

Who can access the Outreach Worker program?

The Aboriginal Outreach Worker program is available to any Aboriginal and Torres Strait Islander person who:

• Has decided to see a doctor and take care of their health
• Needs some support on their health journey

For further details about accessing this program, please contact your local AOW provider. Please note this program is only available to Aboriginal and Torres Strait Islander people accessing mainstream General Practice. Contact details can be found below under ‘Commissioning of Integrated Team Care’.

Commissioning of Integrated Team Care

In 2017, NCPHN commissioned AOW and Care Coordinator components of the ITC program to new service providers. This means that the local referral process has changed. IHPOs were retained by NCPHN and continue to work collaboratively with the broader ITC team.

Who are the new service providers?

NCPHN is pleased to announce the appointment of providers for Integrated Team Care. The list of new providers and their contact details are available below:

For Aboriginal and Torres Strait Islander clients accessing mainstream General Practice:

Rekindling the Spirit
Covering Tweed, Byron, Ballina, Lismore, Richmond Valley, Kyogle and Clarence Valley LGAs
Suite 5, 107-109 Molesworth St, Lismore NSW 2480
Phone: 02 6622 1117

Coffs Harbour GP Super Clinic
Covering Coffs Harbour, Bellingen and Nambucca LGAs
51 Stadium Dr, Coffs Harbour NSW 2450
Phone: 02 6691 3573

Werin Aboriginal Medical Service
Covering Port Macquarie and Kempsey LGAs
14 Lake Road, Port Macquarie NSW 2444
Phone: 02 6589 4000

For Aboriginal and Torres Strait Islander people accessing Aboriginal Medical Services:

Bugalwena General Practice
24 Minjungbal Dr, Tweed Heads South NSW 2486
Phone: 07 5513 1322

Bullinah Aboriginal Health Service
120 Tamar Street, Ballina NSW 2478
Phone: 02 6681 5644

Jullums Aboriginal Medical Service
51 Uralba Street, Lismore NSW 2480
Phone: 02 6621 4366

Bulgarr Ngaru Medical Aboriginal Corporation – Richmond Valley
153 Canterbury St, Casino NSW 2470
Phone: 02 6662 3514

Bulgarr Ngaru Medical Aboriginal Corporation – Clarence Valley
131 Bacon St, Grafton NSW 2460
Phone: 02 6643 2199

Galambila Aboriginal Health Service
9 Boambee Street, Coffs Harbour NSW 2450
Phone: 02 6652 0800

Darrimba Maarra Aboriginal Health Clinic
13-42 Bowra Street, Nambucca Heads NSW 2448
Phone: 02 6598 6800

Durri Aboriginal Corporation Medical Service
15-19 York Lane, Kempsey NSW 2440
Phone: 02 6560 2300

Werin Aboriginal Corporation
14 Lake Road, Port Macquarie NSW 2444
Phone: 02 6589 4000

For further information on Integrated Team Care please contact an NCPHN Indigenous Health Project Officer in your local area:

Tweed Valley
Phone: 07 5589 0500

Northern Rivers
Phone: 02 6627 3300

Mid North Coast
Phone: 02 6562 1055

Hastings Macleay
Phone: 02 6562 1055