Chronic Diseases

Integrated Team Care

On 1 July 2016, Care Coordination and Supplementary Services (CCSS) and Improving Indigenous Access to Mainstream Primary Care (IIAMPC) activities combined to form the Integrated Team Care (ITC) Activity.

The aims of the ITC Activity are to:

  • contribute to improving health outcomes for Aboriginal and Torres Strait Islander peoples with chronic health conditions through better access to coordinated and multidisciplinary care and
  • 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 peoples.

Care coordinators work in their PHN region across the Indigenous and mainstream primary care sectors to assist Aboriginal and Torres Strait Islander peoples to obtain primary health care as required, provide care coordination services to eligible  people with chronic disease who require coordinated, multidisciplinary care, and improve access for Aboriginal and Torres Strait Islander peoples to receive culturally appropriate mainstream primary care.

To be eligible for care coordination under the ITC Activity, Aboriginal and Torres Strait Islander patients must be enrolled for chronic disease management through 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 Activity.

Download: Indigenous Australians' Health Programme Guidelines and Frequently Asked Questions

NT PHN commissions service provider organisations throughout the NT to deliver the ITC program. Between 1 July 2016 and 31 December 2016 the ITC activity will be in a transition period as preparations are made to fully commission all ITC activities on 1 January 2017. During this time the CCSS program will operate as usual.


Health Stream Lead, Paul Ryan
t 08 8950 4810  e