Integrated Team Care (ITC)

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). [1]

On behalf of the Australian Government, Healthy North Coast 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?

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:

  • self-identification.
  • 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.

More information?

For more information please refer to the Australian Government Department of Health Integrated Team Care Guidelines.

[1] Healthy North Coast (2018), Aboriginal Health Needs Assessment.

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Get in touch with our Aboriginal Health team

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Update provided 21 April 2022.

As you know, Lismore Skin Clinic in Molesworth Street was destroyed in the recent floods, and we are trying to rebuild the site as soon as we can.

In the meantime we will be moving to St Vincent’s Hospital Specialist Medical Centre – Level 4, Suite 12 – 20 Dalley Street Lismore.

We hope to be up and running in the next two weeks (by early to mid May 2022) and our receptionists will soon begin calling our patients to rebook their appointments and catch up with their needs.

Once we have a firm opening date we will update this notification.

Our email address – [email protected] and our phone number – 02 6621 3500 will remain the same as in the past. Only the address changes for a while.

We look forward to seeing you soon in our new premises.

Many thanks for your patience and understanding in these heartbreaking times – stay safe.

Dr Gudmundsen and the Team from Lismore Skin Clinic


Contact our Education Team

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Nigel Cronin
Senior Manager, Education
[email protected]
0437 169 786
02 6627 3390
Based on Bundjalung Country in Lismore

Bronwyn Thirkell
Centre for Healthcare Knowledge & Innovation and Education and Events Coordinator NNSW
[email protected]
0437 027 751
02 6618 5445
Based on Bundjalung Country in Ballina

Krissi Devlin
Education and Events Coordinator MNC
[email protected]
0447 407 473
02 6659 1808
Working days: Monday Thursday.
Based on Gumbaynggirr Country in Coffs Harbour

Mental Health Practitioner Directory

Frequently Asked Questions

Any AHPRA or AASW registered mental health practitioner providing services in the Mid North Coast and/or Northern NSW.

Social workers, psychotherapists and counsellors are ineligible to list in the directory.

By listing, you will let GPs, other referrers and consumers know that you are practising in Mid North Coast and/or Northern NSW. You can provide information such as where you are located, the services you provide, the population groups you support and your clinical interests.

No, the directory is a free service provided by Healthy North Coast.

This directory enables you to provide real-time information about your availability to accept referrals, as well as how long people may have to wait for an appointment. You can update this information as your availability changes. This will help GPs and other referrers ensure they only refer clients to practitioners who have the capacity to see them.

It also has a range of advanced search options and supports printing and bookmarking of search results.

You can choose to display your email address and your phone number so that people can contact you directly. You may prefer not to display these, in which case people can contact you by completing an enquiry form located in the Directory. Your choices can be updated anytime.

You can indicate wait times for an appointment for a new client or that you are currently unable to accept new referrals. You can also choose whether to display or hide your contact details. You can update your choices at any time.

Yes, you can update your listing or remove it at any time by clicking the “update practitioner details” button on your listing. You will receive a secure website link to your nominated admin email that will enable you to make changes, delete or put your listing on hold. You can also show when you are taking extended leave or are not available for a specific period, rather than completely removing your listing.

We will also send you an email every three months (90 days) prompting you to check that your information is up to date.

You will be responsible for managing the information in your listing and ensuring that it is up to date. You will also be asked to check the information before it is published in the directory.

We will also send you an email every three months (90 days) prompting you to check that your information is up to date so that the directory displays accurate information.

You can read the full Terms of Use by clicking here.