The Integrated Team Care Program is a crucial initiative designed to enhance the health management of Aboriginal and Torres Strait Islander people who are living with complex chronic health conditions. This program is structured to connect individuals with a comprehensive network of support, including care coordinators, Aboriginal outreach workers, supplementary services, and vital social supports.
Initially launched in 2016 and running through to 2022, the integrated team care program has been recognized for its positive impact and has been recommissioned in an enhanced format, extending its reach until 2025. This recommissioning underscores the ongoing commitment to improving healthcare access and outcomes for Aboriginal and Torres Strait Islander communities.
Enhanced Objectives of the ITC Program
The enhanced integrated team care program builds upon its initial success by incorporating psychosocial funding into its core objectives. These objectives are strategically designed to create a holistic and effective healthcare framework:
- Improved Chronic Condition Management: The primary aim is to contribute to significantly better treatment and management of chronic conditions for Aboriginal and Torres Strait Islander individuals enrolled in the program. This involves personalized care plans and consistent monitoring to ensure effective health management.
- Enhanced Access to Healthcare: By providing care coordination and supplementary services, the program directly improves access to appropriate healthcare for eligible Aboriginal and Torres Strait Islander people dealing with chronic diseases. This reduces barriers to healthcare and ensures timely and relevant interventions.
- Fostering Collaboration in Healthcare: The integrated team care program is designed to foster strong collaboration and mutual support between mainstream primary care services and the Aboriginal health sector. This partnership ensures culturally sensitive and effective healthcare delivery.
- Building Capacity for Culturally Appropriate Care: A key objective is to enhance the capacity of mainstream primary care services to deliver culturally appropriate services tailored to the unique needs of Aboriginal and Torres Strait Islander people. Cultural competency training and resources are integral to this objective.
- Increased Utilization of MBS Items: The program aims to increase the uptake of specific Medicare Benefits Schedule (MBS) items designed for Aboriginal and Torres Strait Islander people. This includes promoting Health Assessments for Aboriginal and Torres Strait Islander people (MBS item 715) and subsequent follow-up items, ensuring access to entitled benefits.
- Community-Based Psychosocial Support: Recognizing the critical link between social and emotional wellbeing and physical health, the enhanced program provides non-clinical, community-based supports. These are aimed at improving the social and emotional wellbeing of participants, their families, and their wider community, addressing holistic health needs.
This sixth objective, emphasized by NWMPHN, highlights the program’s evolution towards a more comprehensive approach. By integrating social and emotional wellbeing support, the integrated team care program aims to holistically improve clients’ capacity to manage their chronic health conditions, acknowledging the interconnectedness of mental, emotional, and physical health. This enhancement was a direct response to consultations with healthcare providers and community members, who stressed the positive impact of SEWB support on overall health outcomes and engagement with healthcare services.
Eligibility for the Integrated Team Care Program
To be eligible for the integrated team care program, individuals must meet specific criteria to ensure that the program reaches those who need it most:
- Indigenous Identity: Clients must identify as Aboriginal and/or Torres Strait Islander.
- Complex Chronic Conditions: Participants are required to have complex chronic health conditions that necessitate ongoing and coordinated care.
- Need for Care Coordination: Eligibility includes those who require care coordination or Aboriginal outreach worker support to effectively manage their chronic health conditions.
- GP Referral: Referral by a General Practitioner (GP) is necessary, initiated through an Aboriginal and Torres Strait Islander Peoples Health Assessment (MBS item 715) or a Chronic Disease GP Management Plan (MBS item 721).
Experienced Service Providers
The recommissioned integrated team care program is implemented by four experienced service providers. These providers have a proven track record of delivering the ITC program effectively for over seven years. Their established presence and deep-rooted connections within Aboriginal and Torres Strait Islander communities are vital to the program’s success. These strong relationships ensure trust, cultural understanding, and effective program delivery, ultimately leading to better health outcomes for participants within the integrated team care program.
