How do we support integrated team care?
We commission services to employ care coordinators so they can take an integrated team care approach.
Care coordinators are qualified health workers, such as nurses and Aboriginal health workers, with clinical skills who can understand patients’ health needs and know how to help with those needs.
They work across Indigenous and mainstream primary care sectors to assist Aboriginal and Torres Strait Islander peoples to obtain primary health care.
In particular, they provide care coordination services to eligible people with chronic disease who require multidisciplinary care, which also improves access for Aboriginal and Torres Strait Islander peoples to receive culturally appropriate mainstream care.
What are the aims of integrated team care?
Integrated team care aims to:
- improve health outcomes for Aboriginal and Torres Strait Islander peoples with chronic health conditions, through better access to coordinated and multidisciplinary care
- close the gap in life expectancy by improving access to culturally appropriate mainstream primary care services (including but not limited to general practice, allied health and specialists) for Aboriginal and Torres Strait Islander peoples.
Who's eligible to receive integrated team care?
To be eligible, Aboriginal and Torres Strait Islander patients must:
- be enrolled for chronic disease management through a general practice or an Aboriginal Medical Service
- have a GP management plan
- be referred by their GP.
Please note that dental is not an eligible condition for the purposes of integrated team care.
For more information on integrated team care, please contact us by completing the form below.
Integrate Team Care (ITC) Review
NT PHN’s 2025 review of the Integrated Team Care (ITC) program found it delivers positive outcomes when supported by stable relationships, culturally safe practice and consistent care coordination. Drawing on reports, surveys, interviews and case studies, the review highlights improved health outcomes, better self-management of chronic conditions and reduced preventable hospital presentations, even in remote and complex settings. Ongoing challenges include cultural and communication barriers, geographic access, workforce capacity and reporting systems. The report identifies opportunities to strengthen the program through improved data integration, flexible funding, workforce stability, culturally informed measures and enhanced outreach, particularly as ITC transitions toward greater Aboriginal community control.
