The Integrated Team Care (ITC) program is an Australian Government activity funded through the Northern Queensland Primary Health Network for Aboriginal & Torres Strait Islanders.

The Integrated Team Care program aims to: 

  1. Contribute to improving health outcomes for Aboriginal and Torres Strait Islander people with chronic health disease (CHD) through better access to coordinated and multidisciplinary care; and
  2. Contribute to closing the gap in life expectancy by improved 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 people.

The program targets Aboriginal & Torres Strait Islanders who have had CHD for more than six months and are either self-referred or referred by the GP as needing additional support.

The thought behind the program

NPAFACS were commissioned by North Queensland Primary Health Network (NQPHN) to deliver the ITC program in the Northern Peninsula Area (NPA) and the outer islands of the Torres Strait. NPAFACS did not have a service footprint on the outer islands, but there are strong family and cultural ties between the NPA and the outer islands. The Board of Directors and staff undertook extensive community consultation on both Badu and Darnley Islands to obtain approval for the delivery of the program.

Following this, sessions were held with local Queensland Health staff for better understanding of the benefits of the program and localised flow charts developed. An agreement(MOU) was also negotiated with TCHHS to ensure a collaborative approach to the delivery of services.

Clients are improving their health

The program has been established at all 3 sites and good outcomes have been achieved. In particular, clients are becoming more health literate and have a greater understanding of their care cycles and service providers.


  • ITC staff and other staff employed by the NPAFACS continue to promote the ITC program despite limited promotional resources. Home visits conducted by staff on the outer islands introduce the ITC program to clients

Uptake of MBS Items

  • Improved client access to the NPAFACS GP Clinic at Injinoo and Bamaga Primary Health Centre (PHC) for developing and reviewing CHD MBS items. The client is taking ownership of their health by attending CHD MBS items’ review when due.
  • Wellbeing weeks were facilitated in conjunction with TCHHS to bring a TCHHS GP to Badu and Darnley Islands to complete the necessary MBS items for a referral to the program. TCHHS were supported by the ITC staff and was a success in both locations

ITC Care Coordination (CC) Support

  • Support provided by the Care Coordinator and Indigenous Outreach Worker (IOW) has increased client access to the NPAFACS GP Clinic and Bamaga PHC for GP, nurse, and CC appointments. The ITC CC support has also minimised the client risk of avoidable hospital admissions and frequent emergency presentations. Care coordinators also ensure support is in place when clients do attend their specialist appointments outside of community by utilising the Indigenous Liaison Officers (ILOs), social workers and nurse navigators.

ITC Supplementary Services (SS) Support

  • Clients accessing ITC SS support have improved their health outcomes by attending specialist appointments outside of community through escort support, accommodation gap and travel assistance. There were also a number of clients identified who had respiratory conditions which required the use of continuous positive airway pumps (CPAP) machines to assist with breathing. These clients are now maintaining a good airway by using the CPAP machines which the ITC program have ordered for them. We have also assisted with other medical aids such as spectacles.

Improved Client Self-Management Skills

  • Clients registered in the ITC program have improved self-management skills through education sessions delivered by the Steel Fitness coordinator, Diabetes Educator and other Allied Health Professionals. Some self-management skills to mention include exercise, healthy eating, walking rather than requesting transport to and from appointments (if living in Injinoo or Bamaga), medication compliance, blood glucose level (BGL) control, attending health education sessions delivered by  health programs.

The ITC program has impacted significantly in the NPA, Badu Island and Darnley Island. With the implementation of the ITC program in the communities, issues have been addresses and gaps were identified.

Improving the quality of care

The number of Aboriginal and Torres Strait Islander Health checks have increased, whereas before the implementation of the ITC program there were a number of clients who would not attend for health checks when requested by health staff. There have also been positive changes in the client GP Management Plans (GPMP) where the long list of “goals to be achieved” are now becoming shorter. As goal are reached this leads to decreased ill-health conditions and better management of Chronic Health Diseases.

Care Coordinators and IOWS have also played a pivotal role  for their clients, acting as interpreters and advocates when attending client GP/specialist appointments. This has given the client a greater understanding their current health  and how to best manage their CHD. This has provided comfort and reassurance for clients experiencing language barriers and now clients feel comfortable attending consultations, clinics and appointments because of the support provided by the ITC team.

Advocating and interpreting play a pivotal role in communicating health information. The services delivered were culturally-appropriate and there is still a need for improvement in delivering culturally-appropriate healthcare. Building trust between patients, Health Workers and GP's has also been addressed to improve clients’ quality of care. Therefore, the ITC program activities in the communities have decreased the factors identified and improved the quality of care.