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Services and Support for Aboriginal and Torres Strait Islander Peoples

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.


Aboriginal people experience significantly poorer health compared to non-Aboriginal people and are at higher risk of developing certain chronic conditions, such as diabetes. If your GP or healthcare provider knows you’re Aboriginal, they can support you to access Aboriginal specific health services and initiatives to empower you to take control of your own health. Examples of specific services available to you include the Integrated Team Care Program, access to the PBS co-payment measure (commonly known as Close the Gap scripts), the 715 annual health check and some additional vaccinations.


Youth Health and Wellbeing Program – La Perouse
Perouse Local Aboriginal Land Council has two Health and Wellbeing Coordinators to engage with and support young people aged 12-25 years. Coordinators help young people access culturally appropriate mainstream services to address their health and wellbeing needs.
Enquiries: 9311 4282 Email:

Youth Outreach Program
headspace Ashfield provides outreach support and link Aboriginal and/or Torres Strait Islander young peoples to local and culturally appropriate services and programs.
Enquiries: 9193 8000 Website:

Youth Health and Wellbeing Program – Inner City
Tribal Warrior Aboriginal Corporation has two Health and Wellbeing Coordinators to engage with and support young people of all ages. Coordinators help young people access culturally appropriate mainstream services to address their health and wellbeing needs.
Enquiries: 9699 3491 Email:

Weave Youth and Community Services: ‘Speak Out’ Dual Diagnosis Program
Care coordination, counselling, information and referral support and group activities for young people with mental health and drug and alcohol support needs. Drop-in centre.
Enquiries: 9318 0539 Website:


ITC Activity is one of the measures under the Closing the Gap scheme aimed at improving chronic disease management for Aboriginal people. ITC includes Care Coordination, Supplementary Services and Outreach Work.

If you have a chronic disease such as Cancer, Diabetes, cardiovascular disease, respiratory disease or renal disease, the ITC Program can assist you with:

  • understanding your chronic health condition and help develop self-management skills
  • understanding of medicines
  • organising medical appointments and access to specialists
  • accessing some pre-approved medical aids
  • facilitate connections to other community support services; and
  • transport options in some cases
  • making positive lifestyle changes to better manage your chronic disease


Care Coordination

Care Coordinators are qualified health workers (for example, nurses, Allied Health professionals or Aboriginal Health Workers) who support you to access the services you need to treat your chronic disease according to your General Practitioner (GP) care plan.

The work of a Care Coordinator can include providing clinical care, arranging the services in your care plans and assisting you to participate in regular reviews by your primary care providers. Care Coordinators work closely with Aboriginal Outreach Workers in many of these activities.


Aboriginal and Torres Strait Islander Care Coordination Program


Supplementary Services

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 your 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 you in accessing some GP approved medical aids.


Outreach Work

Outreach Workers are a component of the ITC Program to encourage you 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:

  • Information and resources about locally available health services
  • Referrals to culturally appropriate health care providers and services
  • Information and assistance with travel options to and from health appointments
  • Support when attending health appointments, including; GPs, specialists, allied health providers and diagnostic tests
  • Assistance with effective communication between yourself and the health care provider
  • Information about local community services and activities

ITC Activity is provided by South Eastern Sydney LHD, Sydney LHD and the Sydney Children’s Hospitals Network.


Aboriginal and Torres Strait Islander Outreach Worker Program


For more information about ITC please contact:

South Eastern Sydney LHD

Phone: 9540 8181


Public hospitals in South Eastern Sydney include:


Prince of Wales

Royal Hospital for Women

St George


Sydney & Eye Hospital

War Memoria


Sydney LHD

Phone:  1300 722 276


Public hospitals in Sydney LHD include:




Royal Prince Alfred


Sydney Children’s Hospitals Network

Phone: 9382 1055



The Sydney Children’s Hospital (SCH) offers an Aboriginal focused speech pathology service, which aims to deliver flexible and culturally appropriate services to Aboriginal Children and their families. For more information, please contact: 9382 1021


PSS provides FREE short-term face to face psychological services for underserviced groups. Services are delivered by appropriately trained and qualified mental health professionals including: Psychologists (general and clinical), mental health nurses, mental health accredited social workers, mental health accredited occupational therapists and Aboriginal and Torres Strait Islander mental health workers. To find out more look for PSS 54 on this page – click here

  • Weave Youth and Community Services: ‘Speak Out’ Dual Diagnosis Program

Care coordination, counselling, information and referral support and group activities for young people with mental health and drug and alcohol support needs. Drop-in centre.
Enquiries: 9318 0539 Website:

  • Drug and alcohol program – Community Restorative Centre

Provides holistic outreach-based rehabilitation to support community reintegration on release from custody. Accessible via a Service and Programs Officer (SAPO), parole officer or case-manager. Enquiries: 9288 8700 Website:

  • Redfern Aboriginal Medical Service (AMS) Drug and Alcohol Treatment Program

What is the AMS Drug and Alcohol Treatment Program?

The Aboriginal Medical Service (AMS) Drug and Alcohol Treatment Programme provides culturally appropriate non-residential treatment programmes, pharmacotherapies, counselling, referral services and aftercare.

The AMS provides a range of services including:

  • Client focused health promotion including harm minimisation advice
  • Infectious disease screening and contact tracing
  • General primary medical care
  • Counselling for drug and alcohol issues
  • Methadone maintenance and buprenorphine out-patient detoxification and maintenance pharmacotherapy treatment programs
  • Outpatient rehabilitation services
  • Outreach counselling
  • Referral services
  • Dual diagnosis management in conjunction with AMS general medical, psychiatry and psychology clinics


  • Aboriginal and Torres Strait Islander people that are registered patients/clients of the service and their families.
  • Clients over 18 who present with substance use.

How to access the service?

Self-referral or via an allied health service.

Contact Details

Aboriginal Medical Centre
Drug and Alcohol Treatment Program
36 Turner Street, Redfern, NSW 2016.
Phone: (02) 93195823

  • We Help Ourselves (WHOS) withdrawal management

What is the Withdrawal Management service?

WHOS deliver an innovative community based ambulatory model of Withdrawal Management care for low-to-moderate withdrawal needs. This service is based at the WHOS Rozelle site for people who present for admission to the WHOS Residential Programs. It provides clients with support for detoxification before entering further treatment with WHOs, within a community-based environment with access to support from the existing day programs.

CESPHN also fund identified Aboriginal and Torres Strait Islander Engagement Officer positions at WHOs, who work across the day residential programs to provide culturally appropriate support.


Clients will be assessed for suitability to the WHOS Withdrawal Management program or may be referred for hospital detoxification.

How to access the service?

Self-referral, via an allied health service, by application from a general practitioner working in collaboration with SLHD or SESLHD departments/detoxes or a WHOS nurse.

Contact Details

Phone: (02) 85727444

Service Manager: Carolyn Stubley (Nurse Manager) WHOS: 8572 7471

  • Odyssey House

What is Odyssey House Community Services (OHCS) and who can use it?

Odyssey House Community Services delivers a range of free alcohol and other drug (AOD) services within a holistic stepped care treatment model. The model includes aftercare support, psychosocial counselling for individuals with co-occurring substance misuse and mental health (MH) disorders with access to individual care co-ordination and counselling. Programs are flexible, evidence based, client centred, and aim to achieve positive client outcomes through an integrated approach and include:

  • Aftercare
    The Odyssey House Community Services Aftercare services are designed as a two stage AOD recovery program that a client can access at either the commencement of their treatment journey or at the end of their time in a residential AOD service or for support post relapse. The model is designed to be responsive to client needs such as education regarding substance misuse, providing relapse prevention education and care coordination that will assist with other issues such as housing, unemployment, money management and health or mental health issues. The Aftercare AOD Recovery Groups provide an accessible treatment option for clients who are under the supervision of Community Corrections or are currently engaged in a MERIT Program.
  • Psychosocial Counselling
    The psychosocial counselling services can be delivered in conjunction with aftercare services and aim to equip clients with co-occurring Alcohol and other drugs (AOD) and Mental Health (MH) issues with therapeutic tools which will support and sustain their recovery. There is a Mental Health Recovery group program run over 8 weeks which is focussed on supporting clients through their treatment journey and developing strategies to build resilience and wellbeing.

Clients can also access one on one support through counselling with qualified clinicians.

All services are free and a Mental Health Care Plan is not required.

The Aboriginal and Torres Strait Islander Program, which includes partnerships with Aboriginal organisations and aims to deliver AOD and Wellbeing Men’s and Women’s groups.


  • Current alcohol and/or other drug dependency or history of;
  • Residing in the Central and Eastern Sydney PHN region
  • 18 and over for all programs
  • Under 18 can access for counselling only

How to access the service?

Contact Odyssey House directly 1800 397 739



The Government has introduced assistance to eliminate or lower the cost of Pharmaceutical Benefits Scheme (PBS) medicines for Aboriginal patients living with, or at risk of, chronic disease. The PBS Co-payment measure is a response to identifying that cost is a significant barrier to accessing medicines for Aboriginal people.

How to access the PBS Co-payment measure

You can only access the measure (CtG scripts) from a registered practice or Aboriginal Health Service participating in the Indigenous Health Practice Incentive Program (PIP). Read more about PIP here

It’s important to note, not all medical practices are registered for PIP, and are ineligible to provide CtG scripts. Look for menu option Practices registered for the Indigenous Health Practice Incentive Program  – click here

What medicines are included and excluded on the PBS co-payment measure?

– Prescriptions for PBS General Schedule medicines are covered
– Highly specialised drugs and other medicines provided under special supply arrangements under Section 100 of the National Health Act 1953 are excluded
– Hospital prescriptions are excluded from the Measure

Additional information on the Measure is available here.

Frequently asked questions document here.


CESPHN produce a quarterly newsletter to keep community up to date on all things Aboriginal health and wellbeing. It’s a great way to find out what’s happening in your local community and receive service updates from CESPHN commissioned providers.

Click here to view the latest editions.


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