Integrated Team Care

What is Integrated Team Care?

Integrated Team Care (ITC) is a program that supports you to better manage your chronic condition.

Am I eligible for ITC?

• If you identify as Aboriginal and/or Torres Strait Islander
• If you have one or more diagnosed chronic conditions
• Your doctor has completed a GP Management Plan (GPMP)

What is a GP Management Plan?

A GPMP is completed for people with chronic health conditions who require team-based care from a GP and other health or care providers. Moorditj Koort’s ITC team works with you and your GP to access different services identified in your GPMP.

What are the benefits of ITC?

Personalised support and services that make a real difference to the way you manage your chronic condition:

• Access to specialist and allied health services
• Increased cultural safety in mainstream healthcare services
• Support for mainstream services to help Aboriginal people self-identify
• Financial assistance for specialist consultations, medical aids (e.g. blood sugar monitors, prescription glasses, CPAP machines)

What do you do now?

• Ask your regular doctor to complete a GPMP and ITC referral form
• Your doctor will send the documents to Moorditj Koort
• We will contact you once we receive the referral

Who is part of the ITC Team?

Our ITC team consists of qualified Aboriginal Health Workers with local knowledge and strong community networks.

Care Coordinators

• Attend and advocate on your behalf at medical appointments
• Arrange allied health appointments and referrals
• Organize regular GP visits
• Work with pharmacies to keep your medication up to date
• Liaise with GPs regarding your Care Plan

Outreach Officers

• Transport to and from medical appointments (subject to availability and eligibility)
• Liaise with health providers
• Support you by attending appointments as needed
• Collect and deliver prescriptions
• Assist with paperwork at appointments

Need More Information?

Download our ITC brochure:

To refer a client, download the GP Referral Form:

Complete and email to [email protected]