Integrated Care and GP Support

Integrated care is about ensuring patients or clients get better care by coordinating the different services they receive.

We aim to:

assist Aboriginal and Torres Strait Islander peoples to access primary health care as required
provide care coordination services to eligible Aboriginal and Torres Strait Islander peoples with chronic disease/s who require multidisciplinary care
improve access for Aboriginal and Torres Strait Islander peoples to culturally appropriate mainstream primary care.

Integrated Team Care in the Hume Region is provided by a team consisting of an Indigenous Health Program Officer, Care Coordinator, and two outreach workers who work closely with patients, GPs, specialists, community services, and allied health professionals to improve patient health.

The Care Coordinator can assist people by:
- helping them to understand their chronic disease through education and clear explanations
- encouraging and supporting them to follow their Care Plan
- arranging specialist/allied health appointments
- linking them with community services that may be needed
- facilitating travel to appointments.
The Care Coordinator can also access the Supplementary Service fund on behalf of the eligible client to assist with allied health or specialist services and some approved medical equipment costs.

To be eligible for care coordination a patient must have one or more of the following chronic diseases:
- Diabetes
- Cancer
- Chronic Respiratory Disease
- Cardiovascular Disease
- Chronic Renal Disease
Other Chronic conditions may be considered.

Access

This service is available to all Gateway Health and other medical practice clients who identify as Aboriginal or Torres Strait Islander. We also support medical practices working with Aboriginal and Torres Strait Islander communities.

The service is provided free of charge, drawing on funds provided by the Department of Prime Minister and Cabinet.

Wodonga – Phone 02 6022 8888
Wangaratta – Phone 03 5723 2000
Email inquiries to info@gatewayhealth.org.au

Note: To access the Care Coordinator a patient must:

be referred by their usual General Practice who is registered for the Indigenous Health Incentive
have a current Care Plan, either a GP Management Plan or a Team Care Arrangement outlining health needs
have complex eligible health needs which require support and assistance.

Priority is given to patients most in need.

The Integrated Team Care program combines the former Care Coordination and Supplementary Services (CCSS) and Improving Indigenous Access to Mainstream Primary Care (IIAMPC) programs. It recognises and builds on the success of both activities, and strengthens a team-based approach for the provision of coordinated, multidisciplinary care.