Aboriginal people on the North Coast have a higher rate of chronic health conditions which lead to hospitalisation (Mid North Coast 4,055 per 100,000 Aboriginal persons) (Northern NSW 3,391) when compared to the overall rate for Aboriginal people across NSW (2,826). 
On behalf of the Australian Government, NCPHN commissions Integrated Team Care Program (ITC) providers across the North Coast to support Aboriginal people with chronic illnesses to access the health care they need.
The aims of the ITC Program are to:
- contribute to improving health outcomes for Aboriginal and Torres Strait Islander people with chronic health conditions through access to care coordination, multidisciplinary care, and support for self-management; and
- improve 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.
Who are the North Coast Integrated Team Care providers?
- Galambila AHS
- Barunga Coffs Harbour GP Super Clinic (Mainstream general practices in Coffs)
- Durri Aboriginal Corporation Medical Service
- Werin Aboriginal Corporation
- Werin Aboriginal Corporation (Mainstream general practices in Hastings Macleay)
- Bullinah Aboriginal Health Service
- Rekindling the Spirit (Mainstream general practices in Northern NSW)
- Rekindling the Spirit – Jullums Aboriginal Health Service
- Bulgarr Ngaru Medical Aboriginal Corporation – Clarence and Richmond Valley Clinics
- Bulgarr Ngaru Medical Aboriginal Corporation – Bugalwena General Practice, Tweed Heads
Care Coordination is provided by qualified health workers, which include nurses and Aboriginal Health Workers, to support eligible patients to access the services they need to treat their chronic disease according to the General Practitioner (GP) care plan. The work of a Care Coordinator can include providing clinical care, arranging the services in patients’ care plans and assisting patients to participate in regular reviews by their primary care providers. Some services also have Aboriginal Outreach Workers who encourage Aboriginal people to access health services and help to ensure that services are culturally appropriate.
Care Coordinators and Aboriginal Outreach Workers have access to a Supplementary Services Funding Pool when they need to expedite a patient’s access to an urgent and essential allied health or specialist service, or the necessary transport to access the service, where this is not publicly available in a clinically acceptable timeframe. The Supplementary Services Funding Pool can also be used to assist patients to access GP-approved medical aids.
The eligibility criteria for accessing the ITC program is Aboriginal and Torres Strait Islander clients enrolled for chronic disease management in a general practice or an AMS, have a GP Management Plan and be referred by their GP. Dental is not an eligible condition for the purposes of the ITC Program. A chronic illness is defined under ITC as being an eligible condition that has been, or is likely to be, present for at least six months. Priority is given to clients with complex chronic care needs who require multidisciplinary coordinated care in order to manage their chronic disease/s.
Indigenous Health Program Officers have a policy and leadership role. They work to improve the integration of care across the region and develop and the capacity of mainstream primary care providers to deliver culturally appropriate primary care services to Aboriginal and Torres Strait Islander people, including taking an advocacy role in:
- uptake of Aboriginal and Torres Strait Islander specific MBS items including item 715 – Health Assessments for Aboriginal and Torres Strait Islander People, care planning and follow up items.
Indigenous Health Program Officers are employed by NCPHN and located across the region.