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Integrated team care for chronic diseases

Integrated team care for chronic diseases

Integrated team care means taking a coordinated approach to the care of Aboriginal and Torres Strait Islander people so they can access multidisciplinary care and receive support to self-manage their condition. It also improves access to culturally appropriate primary care services such as general practice, allied health and specialists.

How do we support integrated team care?

We commission services to employ care coordinators so they can take an integrated team care approach.

Care coordinators are qualified health workers, such as nurses and Aboriginal health workers, with clinical skills who can understand patients’ health needs and know how to help with those needs.

They work across Indigenous and mainstream primary care sectors to assist Aboriginal and Torres Strait Islander peoples to obtain primary health care.

In particular, they provide care coordination services to eligible people with chronic disease who require multidisciplinary care, which also improves access for Aboriginal and Torres Strait Islander peoples to receive culturally appropriate mainstream care.

What are the aims of integrated team care?

Integrated team care aims to:

  • improve health outcomes for Aboriginal and Torres Strait Islander peoples with chronic health conditions, through better access to coordinated and multidisciplinary care
  • close the gap in life expectancy by improving 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.

Who's eligible to receive integrated team care?

To be eligible, Aboriginal and Torres Strait Islander patients must:

  • be enrolled for chronic disease management through a general practice or an Aboriginal Medical Service
  • have a GP management plan
  • be referred by their GP.

Please note that dental is not an eligible condition for the purposes of integrated team care.

For more information on integrated team care, please contact us by completing the form below.

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Programs

Unlike other Primary Health Networks, we have a rural workforce agency.

This Include:

Low-intensity mental health services

Low-intensity mental health services

Low-intensity mental health services

Low-intensity mental health services

Low-intensity mental health services

Low-intensity mental health services

Low-intensity mental health services

Low-intensity mental health services

Low-intensity mental health services

Low-intensity mental health services

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