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 Health Network (SNHN) 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 SNHN 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; or 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.

Ruby van Kool

Integrated Team Care (ITC) Program Manager  |  NSLHD Aboriginal Health Service
Level 3 Community Health Building, RNSH
PH: 9462 9012 | Mob: 0419 485 028 | Email: Ruby.VanKool@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 Health Network boundary


The Integrated Team Care (ITC) program is a chronic disease management program designed to support and improve health outcomes for Aboriginal and Torres Strait Islander People in the region. The service provides culturally appropriate care coordination to Aboriginal and Torres Strait Islander people with long-term, complex conditions. The ITC team at the Sydney North Health Network works closely with clients, general practitioners, and other medical and allied health providers involved in client care.

This service has assisted over 60 people in 2017/18 in the ongoing management of their conditions, providing a range of supplementary services, including transport, payment of allied health and specialist medical appointments, medication management, and access to medical aids. The service also provides care coordination, facilitating social supports such as Centrelink, housing and emotional wellbeing services.

Working with individual clients often highlights needs in other members of the family, and the ITC program has been instrumental in referring these family members on to a range of services.

During 2017/18, the Sydney North Health Network has developed and implemented a range of initiatives and programs aimed at supporting culture, health and wellbeing within Aboriginal and Torres Strait Islander communities across the Northern Sydney region.

Indigenous Eye Health Clinics

In partnership with Dresden Optics, NSW Rural Doctors Network and Vision Australia, SNHN provided indigenous eye health clinics for communities within the Manly and Ryde local government areas. Eye clinics were also provided to students at 9 schools in the Hornsby and Lane Cove regions. A total of 180 students were screened, with 65 students requiring and receiving spectacles.


Culture, Health and Wellbeing

SNHN has facilitated the development and implementation of several cultural, health and wellbeing initiatives across the Northern Sydney region including:

  • The Caber-ra Nanga Wellbeing Ceremony held at the Narrabeen Sport Centre in February 2018, attracting over 170 people, including local community members and health and wellbeing services.
  • On Track at Christmas – introduced to the Ryde region in December 2017. On Track is designed to bring local families together, enjoy cultural food and games, and help people develop their own sense of self through mindfulness.

Improving Cultural Fitness in Primary Care

SNHN has partnered with TAFE NSW to provide the Aboriginal Cultural Education Program. The program aims to equip primary care providers with a better understanding of the health and emotional issues that face Aboriginal peoples in our region. The program supports general practice, allied health and commissioned services.


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“I think the Women’s Gathering is helping me come out of my depression.”

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“The Yarning Circle at the Riverview Eye Clinic provided a young Aboriginal man with 6 months’ worth of therapy.”
Leanne Neal – Health Care Coordinator

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