Integrated Team Care (ITC) team
Aboriginal and Torres Strait Islander people with a chronic disease can be referred to the ITC by their GP for assistance with specialist appointments, transport, accommodation, and medical aids.
Any practice with an Aboriginal client eligible for the service can make contact with the ITC team. The team will discuss the needs of the client with the referring practice and the client, and put plans in place to address these needs (e.g. assist in completion of necessary paperwork, arranging payment of specialist gap fees, arranging travel and accommodation logistics around a specialist appointment, organising local transport). The support provided would be communicated back to the referring GP. The ITC team will make the payments required either on receipt of an invoice from the specialist service or up front where that was required e.g. accommodation and transport.


What is Integrated Team Care?
The Care Coordination and Supplementary Services (CCSS) and the Improving Indigenous Access to Mainstream Primary Care (IIAMPC) activities have been combined to form the Integrated Team Care (ITC) Activity. ITC formalises a team approach so that Aboriginal and Torres Strait Islander patients will be supported across the full pathway of care, from encouragement and assistance to accessing health care through to provision of multidisciplinary care.
For the purpose of the ITC Activity, care coordination means working collaboratively with patients, general practices, Aboriginal Medical Services, and other service providers to assist with the care coordination of eligible patients with chronic disease. The ITC team is also committed to working with mainstream primary health care services to ensure they offer a culturally appropriate service to Aboriginal and Torres Strait Islander clients.
Bendigo and District Aboriginal Cooperative delivers Integrated Team Care (ITC) in the Dja Dja Wurrung area. The ITC team consists of the Aboriginal Health Project Manager, Aboriginal Outreach Worker and Chronic Care Coordinator.


Who is eligible to be assisted by the ITC team?

PLEASE NOTE: to be eligible you must reside in the Dja Dja Wurrung Catchment Area (see map below)

Aboriginal and Torres Strait Islander patients, including children, who have a diagnosed chronic condition, are enrolled for chronic disease management in a general practice or Aboriginal Medical Service and have a GP Management Plan in place.
GPs are encouraged to provide an eligible patient with a Medicare plan such as an ATSI health check (MBS item 715), GPMP (MBS item 721) and/or Team Care Arrangements (MBS item 723).
How do you access the program?
GP completes ATSI health check (MBS 715)
GP competes GP management plan (MBS 721)
GP assesses the patient’s needs for extra services and refers an eligible patient to ITC team
The ITC team reviews the referral. If accepted, the ITC team will follow up with the patient and feedback information to the referring GP.

Please click here for the Referral form

Examples of care coordination
1. Client X attends GP Dr Y for diabetes care. The client is not compliant with his medication, has not seen an endocrinologist for 2 years or had any complication screening done. While Dr Y has given the client referrals, he has not attended the appointments.
Dr Y will refer Client X to ITC. He will follow-up by sending the GP management plan and indicating those aspects of the plan that are most urgent. In the described case this might include referrals to an endocrinologist, podiatrist, ophthalmologist/optometrist and pharmacist. The ITC team will identify some referral options both within or outside BDAC, recognising different patient preferences. Appointments will be made, transport arranged, gap payments made if required. Feedback will be provided to the GP for the client’s medical record.

2.Client A is diagnosed with diabetes. GP Dr B refers Client A to the ITC team for assistance. GP Dr B’s instructions in the Client As care plan may indicate that she urgently needs podiatry services. If the ITC team is unable to urgently access podiatry services for Client A through the public health system, the ITC team can arrange to pay for an appointment with a private podiatrist, using the Supplementary Services Funding Pool, and then arrange for ongoing care through the public system. If Client A cannot access or afford transport to attend appointments relevant to their care plan, the Outreach Worker can drive her to the appointments, or Supplementary Services Funding Pool can be accessed to pay for the necessary transport.
Client A may require assistance with learning how to monitor her blood glucose levels. In accordance with her care plan, the Care Coordinator, who has the relevant qualification and skills, can teach Client A how to monitor her blood glucose levels and support her as needed.

How to make contact with the ITC team:

Charlie Knight, Aboriginal Outreach Worker
Phone: 0437 424 949
Email: [email protected]

Paul Skipper, Chronic Care Coordinator
Phone: 03 5442 4947
Email: [email protected]

Violet Pearson, ITC Administration Worker
Email: [email protected]