Mainstream primary care has an important role in ensuring better service provision, including improved health assessment uptake. The CESPHN Aboriginal Health and Wellbeing program aims to improve the capacity of mainstream primary care services to deliver culturally sensitive services to Aboriginal and Torres Strait Islander peoples. CESPHN also work with Aboriginal Community Controlled Health Services, including Aboriginal Medical Services to support improved Aboriginal Health and Wellbeing.
From 2016-17, the Improving Indigenous Access to Mainstream Primary Care (IIAMPC) activities and the Care Coordination and Supplementary Services (CCSS) have been combined to form the Integrated Team Care (ITC) Activity.
ITC Activity is one of the measures under the Closing the Gap scheme aimed at improving chronic disease management for Aboriginal and Torres Strait Islander people. ITC includes Care Coordination, Supplementary Services and Outreach Work.
Care Coordination is provided by a qualified healthcare worker to Aboriginal and Torres Strait Islander people with a chronic condition such as respiratory disease, renal disease, cardiovascular disease, diabetes or cancer.
Care Coordinators are qualified health workers (for example, nurses, Allied Health professionals or Aboriginal Health Workers) who support eligible patients to access the services they need to treat their chronic disease according to the General Practitioner (GP) care plan.
The work of a Care Coordinator can include providing clinical care, arranging the services in patients’ care plans and assisting patients to participate in regular reviews by their primary care providers. Care Coordinators work closely with Aboriginal Outreach Workers in many of these activities.
Care coordinators who will work collaboratively with GPs in accordance with the client’s care plan. The care coordinators may assist clients in a number of ways:
Aboriginal and Torres Strait Islander Care Coordination Program
ITC has a flexible pool of funds that can be used to assist clients receiving care coordination. The funds can be used to improve access to medical specialist and Allied Health services that are in accordance with the client’s GP care plan.
Care Coordinators have access to a Supplementary Services Funding Pool when they need to expedite a patient’s access to an urgent and essential Allied Health or specialist service, or necessary transport to access the service, where this is not publicly available in a clinically acceptable timeframe.
The Supplementary Services Funding Pool can also be used to assist patients to access some GP approved medical aids.
Outreach Workers are a component of the ITC Program to encourage Aboriginal and Torres Strait Islander people to access health services and help to ensure that services are culturally competent. They have strong links to the community they work in.
The Aboriginal Outreach Worker provides non-clinical services including the following:
ITC Activity is provided by South Eastern Sydney LHD, Sydney LHD and Sydney Children’s Hospitals Network. All services provided through ITC are funded through CESPHN, and there are no direct costs to patients.
Aboriginal and Torres Strait Islander Outreach Worker Program
South Eastern Sydney LHD
Phone: 9540 8181
Phone: 1300 722 276
Sydney Children’s Hospitals Network
Phone: 9382 1055
Available to any Aboriginal and/or Torres Strait Islander patient who has received a health check, and the need for allied health services was identified. Maximum 5 services per year.
Referral to Allied Health for Follow Up Services for Aboriginal and Torres Strait Islander people Factsheet
Follow-up Allied Health Services for People of Aboriginal and Torres Strait Islander Descent (MBS Items 81300-81360) Fact Sheet
Referral to Allied Health Template
Indigenous follow up referral form
Aboriginal Employment Strategy
Address: 1/13-17 Cope St, Redfern NSW 2016, Australia
Phone: (02) 8571 0900
Services: A not-for-profit organisation that specialises in placing and mentoring Aboriginal people into employment
Aboriginal Health and Medical Research Council
Phone: 9212 4777
Address: 35 Harvey Street Little Bay NSW 2036
Area Served: NSW
Services: Advisory service on Aboriginal health and medical services, community information.
Aboriginal Medical Service
Address: 36 Turner Street REDFERN NSW 2016
Phone: 9319 5823
Hours: Monday to Thursday: 9amto 6pm & Friday: 10am to 5pm
Services: Counselling, diabetes, HACC services, HIV/AIDS, sexual assault, health education, aged care services and Aboriginal health services.
Target Group: Aboriginal and Torres Strait Islanders, Addicts, Carers, People with Disability, Housebound, Older People
Aboriginal Mental Health Services
Contact: Aboriginal Mental Health Worker, Camperdown Community Mental Health Services
Address: Level 5, King George V Building, Missenden Rd Camperdown
Phone: 9515 5000
Area Served: Suburbs of Redfern, Waterloo, Alexandria, Darlington, Chippendale, Erskineville, Newtown (part), Camperdown, Annandale, Glebe, Forest Lodge, Ultimo, Pyrmont, Rozelle, Lilyfield, Leichhardt, Balmain and Birchgrove
Aged Care & Rehabilitation
Contact: Referral & Information Centre (Northern Cluster – SSWAHS)
Phone: 1800 556 533 or 9767 5200
Services: For health service and other information on assistance and services for elderly people in the Ashfield, Burwood, Camperdown, Concord, Canterbury, Canada Bay, Marrickville, Strathfield, Leichhardt and parts of Sydney LGA
Australian Indigenous HealthInfoNet
The Australian Indigenous HealthInfoNet is a web resource that informs practice and policy in Indigenous health by making research and other knowledge readily accessible. The HealthInfoNet is not a provider of health services, nor does it provide crisis support. If you require urgent help, please contact:
Contact: Indigenous Services Unit
Phone: 9243 3429
Indigenous Call Centre: 13 6380
Address: 140 Redfern Street REDFERN NSW 2016
Services: Advocacy, support for Centrelink Indigenous clients in the East and Western areas of Sydney to access to: education, employment and training. Community, engagement and building partnerships.
Community Health Centre – Redfern
Phone: (02) 9395 0444
Contact: Aboriginal Health Worker, Community Nursing
Address: Redfern Community Health Centre, 103-105 Redfern St, Redfern NSW 2016
Services: Generalist community nursing providing assessment, referral and direct care services to people in their own homes.
First Peoples Disability Network Australia (FPDN)
Phone: +61 (02) 9267 4195
Address: Suite 502, Level 5/280 Pitt St, Sydney NSW 2000
Services: Brings together Aboriginal and Torres Strait Islander people in an attempt to address the high degree of unmet need for Aboriginal people with a disability.
Area Serviced: NSW
General Inquiries 24 hr on 1300 468 746
Target Group: Low income earners, pensioners and people with disabilities from18 years who are unable to secure and retain accommodation in the private market
Address: Level 7, 52 Railway Parade, Burwood
Phone: 8372 4700
Address: Ground Floor, 219- 241 Cleveland Street, Redfern
Phone: 9268 3444
Housing Pathways NSW
Temporary Accommodation Line: 1800 155 152
Aboriginal Housing Information Service: 1800 727 555
Hospital Services – Royal Prince Alfred Hospital
Contact: Aboriginal Liaison Officer (Male and Female)
Phone: 9515 9278 (male) & 9515 9277 (female)
Address: Level 6 KGV Building Royal Prince Alfred Hospital, Missenden Road CAMPERDOWN NSW 2050
Services: Advocacy, Counselling, support for Aboriginal patients, liaison with registered nurses, social workers and discharge planners
Royal Prince Alfred Sexual Health Clinic
Contact: Aboriginal Health Worker
Phone: 9515 3131
Address: Page Building, Level 5, Missenden Road, CAMPERDOWN NSW 2050
Services: Sexual health clinics including screening and vaccinations for sexually transmitted infections, HIV/AIDS services, counselling, Aboriginal health centres and women’s health centres Target Group: Aboriginal and Torres Strait Islanders
Indigenous Men’s Sexual Health
Phone: 9515 5297
Address: Ground floor Building 12, Missenden Road, CAMPERDOWN NSW2050
Services: Promotion of Indigenous men’s sexual health, health education, Community information services, aboriginal health centres.
Area Served: Sydney Inner West HACC
Target Groups: Aboriginal and Torres Strait Islanders males
Psychological Support Services (PSS)
PSS provides FREE short term face-to-face psychological services to people in identified underserviced and/or hard to reach populations who live, work or go to school in the Central and Eastern Sydney region with a diagnosable mild to moderate mental illness, who may benefit from short term treatment, and are unable to access other available services including Better Access (Medicare subsidised psychological services).
Salvation Army Community Service Centres
Address: 23 Anglo Road, Campsie
Phone: (02) 9718 7933
The National Aboriginal Community Controlled Health Organisation (NACCHO)
Office: Level 5 East Tower, 2 Constitution Avenue, Canberra City ACT 2601
Postal: GPO Box 299, Canberra ACT 2601
Phone: 6246 9300
Fax: 6248 0644
Wyanga Aboriginal Aged Care Program
Contact: Client Services Officer
Phone: 9319 7175
Address: 35 Cope Street REDFERN NSW2012
Target Group: Aboriginal people over 45 years and carers.
Services: Aged care services, home care and health services