Integrated Team Care (ITC) 

The Integrated Team Care (ITC) activity is one of the measures under the Closing the Gap scheme aimed at improving chronic disease/condition management in Aboriginal and Torres Strait Islander people. ITC includes Care Coordination and Supplementary Services which has two main components:

  • Care Coordination is provided by a qualified healthcare worker to Aboriginal and Torres Strait Islander people with a chronic disease. Patients will be referred by their GP -from a general practice participating in the Practice Incentives Program (PIP) Indigenous Health Incentive and
  • Supplementary Services: A flexible funding pool is available to the Care Coordinator to assist patients to access urgent or essential health services. The funds can be used to improve access to specialist and allied health services that are in accordance with the patient’s care plan.

These services are provided for residents of Canberra through Grand Pacific Health.  All services provided by the Care Coordinator are funded through the Primary Health Network, there is no direct cost to patients.

If you are a GP with an Aboriginal or Torres Strait Isalnder patient who could benefit from the above services please complete the ITC Referral Form and complete a GP Management Plan.

Grand Pacific Health Team Members

Care Coordinator

The Care Coordinator works with Aboriginal and Torres Strait Islander people and their GP to improve health outcomes for Aboriginal and Torres Strait Islander people with chronic conditions, through better access to coordinated and multidisciplinary care. Assisting patients with a chronic disease to access the right service at the right time.

The care coordinator may assist an Aboriginal or Torres Strait patient in a number of ways including:

  • understanding their chronic health condition and learning self-management skills
  • managing their health better
  • accessing other health services identified in a care plan developed by the patient’s GP
  • assisting the patient to participate in regular reviews with their GP
  • advising on the importance of following their care plan and support patients to adhere to their treatment plan
  • connecting patients with community based services as needed
  • supporting patients and families to adopt healthy life-style choices.

Aboriginal Outreach Health Worker

As part of the Closing the Gap program the CtG Aboriginal Outreach Worker is available to support Aboriginal and Torres Strait Islander people to access local health services including GPs, specialists and allied health providers.

The Aboriginal Outreach Worker provides non-clinical services including the following:

  • information and resources about locally available health services
  • information and assistance with travel options to and from health appointments
  • support when attending health appointments, including GPs, specialists, allied health providers and diagnostic tests
  • assistance with effective communication between Aboriginal and Torres Strait Islander people & the health care provider
  • information about local community services and activities.

All services by the Aboriginal Outreach Worker are STRICTLY CONFIDENTIAL. If you are a GP with an Aboriginal or Torres Strait Islander patient who could benefit from any of the above assistance please contact the Grand Pacific Health team.

Information for general practice

Click here to view information for general practice.

Contact us

Please contact the team on 02 4827 0500, or you can email us at itc [at] or phone 6287 8099.