Aboriginal Health

Aboriginal Health

Indigenous Integrated Team Care Program (ITC)

Formerly Care Coordination & Supplementary Services (CCSS)

Support for Aboriginal and Torres Strait Islander people with complex chronic illness

The Sydney North Primary Health Network (SNPHN) have now commissioned the Integrated Team Care (ITC) program to the Northern Sydney Local Heath District (NSLHD) Aboriginal Health Service (AHS). This program is an Australian Government initiative which forms part of the Indigenous Chronic Disease Package (ICDP). This aims to improve health outcomes for Aboriginal and Torres Strait Islander people with chronic health conditions, through better access to coordinated and multi-disciplinary care. ITC is currently available to all practices in the SNPHN region.

The ITC program has three main components:


1. Care Coordination

Care Coordination is provided by the NSLHD Aboriginal Health Care Coordinators who work collaboratively with people and their general practices, Aboriginal health services, medical specialists, allied health professionals and community services to assist in the provision of culturally sensitive health care and services.
For Aboriginal and Torres Strait Islanders enrolled on the ITC program Care Coordinator can:

  • Help people to understand their conditions, medications and treatments;
  • Assist people and their carers to manage one or more of their SEVERE chronic diseases (see below for details);
  • Arrange and remind people and their carers of appointments;
  • Assist people to access specialist and allied health services;
  • Direct people to community programs; and
  • Organise and assist with travel to and from medical appointments.


2. Supplementary Services

Supplementary Services funding may be used to directly pay for services by specialist and allied health providers, or to meet the difference between MBS rebates and fees charged. The funds may also be used to assist with the cost of local transport to and from medical appointments.


3. Development of culturally sensitive health services

The ITC is responsible for improving the cultural sensitivity of mainstream health services to ensure that Aboriginal and Torres Strait islander people are catered for locally.

Who can be enrolled into this program?

The ITC program is open to Aboriginal and Torres Strait Islander people who are at HIGH RISK, such as those that have a SEVERE form of one or more of these chronic diseases: Cancer; Cardiovascular Disease; Diabetes; Renal Disease; Respiratory Disease; Mental Illness.

  • GP needs to have evidence of frequent hospital admissions and/or emergency presentations over a 12 month period;
  • Person is having trouble accessing and using the right services needed for their care; and
  • Person requires coordination to manage multiple services.

How can an Aboriginal person be enrolled?

  • Person must have a current GP Management Plan in place;
  • Person must have a written referral from their GP (Please see referral form at top of page).

If you would like further information regarding the ITC program please contact one of the NSLHD Aboriginal Health care staff.

Mary (Molly) Florance

Clinical Nurse Consultant, Chronic Care
Aboriginal Health Unit
2c Herbert Street, Ground Floor
Royal North Shore Community
Health Centre St Leonards 2065

T: 02 9462 9013
M: 0434 324 690
F: 02 9462 9083
Email: Mary.Florance@health.nsw.gov.au

Program Objectives

The Program’s scope is to coordinate care, fund activities, services, and aids where appropriate, which support the treatment and management of Aboriginal and Torres Strait Islander people with chronic conditions. There should be improved access to primary care, and the promotion of continuity of care where patients need ancillary care, specialised care, or other follow up activities. This is facilitated through better access to the required services in a range of disciplines and allied health services, and better care coordination and provision of supplementary services.


The following general eligibility criterion is mandated by the Department for entry to the ITC program.

That a person:

1. Identifies as Aboriginal and/or Torres Strait Islander

2. Is diagnosed with at least one of the following chronic diseases:

  • Diabetes
  • Cancer
  • Cardiovascular Disease
  • Chronic Respiratory Disease
  • Chronic kidney disease
  • Mental illness

3. Has a completed GP Management Plan and/or completed Team Care arrangement (optional)

4. Resides or attends a General Practice within the Sydney North Primary Health Network boundary

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