Long-term health conditions affect almost 90% of Aboriginal Elders or Torres Strait Islander people over the age of 551. One-quarter of Indigenous people also report problems accessing service providers to support their health and social care needs.

The Integrated Team Care (ITC) Program improves health outcomes for Aboriginal and Torres Strait Islander people with chronic health conditions through access to care coordination, multidisciplinary care and self-management support. It improves access to culturally appropriate, mainstream primary care services, including general practice, allied health and specialists. The program also provides cultural awareness training to medical professionals.

Frank* is a 75-year-old Aboriginal Elder referred to the ITC program by a Community Nurse who noticed that he was having difficulty managing his health appointments. The ITC team met with Frank and his carer at home to review their support needs. The team identified that Frank had no family support besides his in-home carer, he was at risk of falls, and he wasn’t using any medical aids. He was also under financial strain from sponsoring the visa of his carer, which meant that he was unable to attend specialist medical appointments for his chronic health as these were not bulk-billed.

Through the ITC program, Frank attended specialist appointments and received medical aids to assist with his mobility and reduce his risk of falls. He also gained access to transport for health appointments and allied health
appointments through supplementary service funding. The ITC team made referrals to Legal Aid to assist Frank’s carer to obtain a new visa so that she could continue to support Frank. ITC also reached out to other community programs to help address her own health needs.

ITC has offered to help Frank re-engage with his community once he is feeling more self-assured. Frank is now attending all of his health appointments and feels confident that he has suitable support mechanisms to safely manage his health.


*Name has been changed to protect the identity of this client

[1] Australian Bureau of Statistics (2016), National Aboriginal and Torres Strait Islander Social Survey 2014-2015 

Read more about this service and how to access help.


Download a PDF of this story.

Read more stories from the WW Stories project.