Chronic Disease Team

The Chronic Disease Team consists of:

Chronic Care Co-ordinator for the Integrated Team Care Program
Chronic Disease Nurse
Aboriginal Chronic Disease Outreach Worker
Social worker


Chronic Disease Co-ordinator for the Integrated Team Care Program 

Helping people to understanding their chronic disease through education and clear explanations

Encourage people to follow their Care Plan

Support and encourage patients to develop self-management skills for their chronic condition

Organise patient transport for appointments where required

Assist the patient to participate in regular reviews from their primary care providers

Negotiate specialist and allied health fees where affordability prevents access to service

Arrange specialist/allied health appointments, in some cases provide financial assistance.

Who is Eligible for the ITC Program?

  • Patients MUST be Aboriginal and/or Torres Strait Islander
  • Patients MUST have an existing Chronic Disease to be referred into the program. This may include, but is not limited to, diabetes (including eye conditions associated with diabetes), chronic respiratory disease, chronic cardiovascular disease, chronic renal disease, cancer and some other diseases may be considered – those at risk of a chronic disease are not eligible.
  • Patients MUST require coordinated, multidisciplinary care to improve their health. Just because you have a chronic disease does not mean you are immediately accepted into the Program

*Please note:

  1. Priority is given to chronic and complex patients most in need of assistance.
  2. The ITC Program does not fund everything to do with your chronic disease.


Chronic Disease Nurse

Helps patients with chronic disease management. Ensuring that patients are reaching their health outcomes by providing ongoing support in their journey towards better health.


Aboriginal Chronic Disease Outreach Worker

 Responsible for transporting our Aboriginal Chronic clients to specialist appointments locally and also attending the appointments with them to help them understand what is discussed at these appointments.


Social Worker

Responsible for helping individuals, families, and groups of people to cope with problems they’re facing to improve their patients’ lives. Must be linked in with the CD Team to be able to access.



“We support the Aboriginal community towards a better tomorrow.
Our focus is to work alongside you to create generational health change.”



664 Daniel St


86-90 Rowan Street


12 Stanley Street