Support available for people impacted by the Bondi Junction tragedy: Read more


The role of mainstream General Practice in Aboriginal Health

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 Community Controlled Health Services, including Aboriginal Medical Services to support improved Aboriginal Health and Wellbeing.

Identifying patients of Aboriginal descent

Aboriginal people experience significantly poorer health than that of non-Aboriginal people and are at higher risk of developing certain chronic disease. Identification ensures health care needs can be appropriately met. Practice staff and GPs can support Aboriginal patients to self-identify, which is the essential first step in providing specific health services. A patient is considered to be of Aboriginal descent if they identify as being so. Appearance is not a reliable way of determining cultural identity. Routine identification can be assisted through:

  • staff cultural awareness training
  • improved understanding of the need for and the benefits of health assessments
  • culturally appropriate resources in the waiting room
  • staff being confident when asking patients the question (of ethnic origin) and explaining its importance. An appropriate way to ask is:

“Are you of Aboriginal and/or Torres Strait Islander descent?”

Alternatively, staff may feel more comfortable using a less direct line of questioning, which can then open the conversation for future enquiry. For example:

“Do you identify with a particular cultural background?”

A RACGP fact sheet on identification of Aboriginal and Torres Strait Islander patients can be viewed at: RACGP 3rd Edition Standards Fact Sheet for Identification of Patients.

Health assessments

Health assessment for Aboriginal and Torres Strait Islander People – MBS Item 715

Medical practitioners providing a health assessment for Aboriginal and Torres Strait Islander people should use MBS Item 715. This MBS health assessment item has no designated time or complexity requirements. The length of the health assessment will be at the medical practitioner’s discretion. MBS Item 715 should be used for health assessments for the following age groups:

  • Aboriginal and Torres Strait Islander children who are less than 15 years old
  • Aboriginal and Torres Strait Islander adults who are aged 15 years and over but under the age of 55 years
  • Aboriginal and Torres Strait Islander older people who are aged 55 years and over
  • Healthy Kids Check provided by a practice nurse or Aboriginal and Torres Strait Islander health practitioner – MBS Item 1098
    The MBS health assessment for a Healthy Kids Check provided by a practice nurse or Aboriginal and Torres Strait Islander health practitioner on behalf of a medical practitioner is provided under MBS Item 10986.

NACCHO guide to a Preventative health assessment for Aboriginal and Torres Strait Islander peoples

MBS Item 715 (Health Assessment) Factsheet – Health Assessment for Aboriginal and Torres Strait Islander People (MBS ITEM 715)

MBS information sheet for telehealth-  CESPHN Aboriginal MBS Telehealth support

How to complete 715 Health Assessment Videos

  • 715 Health Assessment Check 0 to 5 years – here
  • 715 Health Assessment Check 5 to 12 years – here
  • 715 Health Assessment Check 12 to 24 years – here
  • 715 Health Assessment Check 25 to 49 years – here
  • 715 Health Assessment Check 50 plus – here

Health Assessment Templates

  • Infants and preschool (birth-5 years) – here
  • Primary school age (5-12 years) – here
  • Adolescents and young people (12-24 years) – here
  • Adults (25-49 years)  – here
  • Older people (50+ years) – here


Aboriginal and Torres Strait Islander health assessments information

Aboriginal and Torres Strait Islander health assessments for GP and health professionals

715 Sharkies

The Deadly Choices program through the Cronulla Sharks are holding a promotion for Aboriginal and Torres Strait Islander Clients in the CESPHN region.

Clients whom have had a 715 health check in the past 6 months may be eligible for a Sharks Deadly Choices shirt, GP’s are encouraged to fill in the attached form with clients and can send it through  to the Cronulla Sharks who will contact client and send shirt to them.

Pharmaceutical Benefits Scheme (PBS) Copayment Measure

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. Additional information on the Measure is available at the Department of Human Services’ Closing the Gap website.

* Please note* 

The CTG PBS Co-payment program changes came into effect on 1 July 2021.

What is changing?

* A centralised patient registration database for the program, managed by Services Australia.

* Any PBS prescriber or AHPRA registered Aboriginal and Torres Strait Islander Health Practitioner registered with Medicare as a provider can register eligible Aboriginal and Torres Strait Islander people for the program.

* Eligible Aboriginal and Torres Strait Islander people can be registered for the program no matter where they live, and regardless of their chronic disease status.

* Registration of eligible Aboriginal and Torres Strait Islander people will be via the Health Professional Online Services (HPOS)

* This registration covers Aboriginal and Torres Strait Islander people even if they move to a
different health clinic.

* PBS prescribers will no longer be legally required to write or electronically print ‘CTG’ on eligible PBS prescriptions for registered Aboriginal and Torres Strait Islander people. However, annotation of a PBS script will help community and Section 94 Approved Private Hospital pharmacists, when dispensing the medicines, know that the patient is registered for the program.

* Any PBS prescriber can issue PBS General Schedule medicine prescriptions for Aboriginal and Torres Strait Islander people that are registered for the program.

* PBS prescriptions issued by PBS prescribers within public hospitals will now be eligible to be dispensed by any community pharmacy or Section 94 Approved Private Hospital pharmacy.

* If Aboriginal and Torres Strait Islander people are registered for the program the PBS Online claiming system will verify this in real time. If the “Closing The Gap’ field in the dispensing system has been completed, this will trigger the correct pricing. If that field has not been completed, a claim will be rejected and will need to be resubmitted.

Please see links for these changes and FAQ’s

Practice Incentives Program (PIP) Indigenous Health Incentive (IHI)

The Practice Incentive (PIP) Indigenous Health Incentive is aimed at supporting general practice, as well as Aboriginal health services to provide a comprehensive range of health services to Aboriginal people with chronic health problems. Financial incentives are arranged into 3 components that are based upon the level of care provided. Practices participating in the incentive will also have increased access to supporting health services for their patients. More information on the PIP Indigenous Health Incentive can be accessed at:

Practices registered for the Indigenous Health Practice Incentive Program

Practices registered for the Indigenous Health Practice Incentive Program

For clinics wishing to provide us information on their PIP IHI registration status and/or consent for us to provide this information on website below please complete form HERE.


Alexandria Waterloo Medical Centre Shop 4, 45 Wyndham Street 9699 1261
Bangor Bangor Medical Centre Shop 6, Bangor Shopping Centre 8582 1318
Bangor Southern Cross Medical Practice – Bangor 32 Pyree Street 9541 2412
Bondi Junction Sapphire Family Medical Practice Shop 2 & 3, 95-99 Bronte Road 8188 2568
Burwood Victoria Tower Medical Suite 3, 36-38 Victoria Street East 8322 9000
Campsie Campsie Medical Practice Shop 3, 20 Ninth Avenue 9789 3333
Earlwood Earlwood Medical Centre 356 Homer Street 9554 7788
Engadine Bethany Medical Centre Shop 1/1018 Old Princes Highway 9030 4373
Five Dock My Family Doctors 52-54 Great North Road 90512885
Glebe Glebe Family Medical Practice 114 Glebe Point Road, Glebe 9660 8399
Kirrawee Kirrawee Family Medical Practice 455 President Avenue, Kirrawee 9521 6261
Kogarah Blue Shield Family General Practice Suite 3, Level 1/19 Kensington Street, Kogarah 9553 7505
Leichhardt General Medical Practice 102 Marion Street, Leichhardt 9569 6051
Leichhardt Leichhardt Medical Centre 6-8 Norton Street, Leichhardt 02 9550 0322
Marrickville Marrickville Medical Practice 221a Marrickville Road, Marrickville 9550 9292
Miranda Miranda Family Practice Unit 1/12 Central Road 02 9540 1200
Punchbowl The Medical Practice 230A The Boulevarde 9740 3900
Ramsgate Saint Mary Family Clinic 13 Tonbridge Street 8558 6600
Ramsgate Ramsgate Beach Medical Centre Ground Floor, 209 Ramsgate Rd, Ramsgate Beach,
02 7923 9103
Redfern Poet’s Corner Medical Centre Shop 5, 45 Morehead Street, Redfern 9698 3060
Riverwood Revival Medical Centre 264 Belmore Road 9153 8311
Roseberry Botany Road Doctors Suite 3, 530 Botany Road 9066 0111
Rozelle Rozelle Total Health 579 Darling Street, Rozelle 9087 4600
Sutherland Shire Family Practice 2/154 Flora Street, Sutherland 9545 1777
Closing the Gap – Integrated Team Care


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

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:

  • assist people in understanding their chronic health condition and help them to develop self-management skills
  • assist with understanding of medicines
  • assist with lifestyle changes and referrals to programs to assist
  • facilitate connections to other community support services
  • organise appointments and/or transport with appropriate services; and
  • advise on the importance of following care plans, for example assisting patients to participate in regular reviews with their GP or recommended follow up appointments with allied health or specialists.


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 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 Work

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:

  • 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 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


To refer into the Aboriginal Integrated Team Care Program

South Eastern Sydney LHD

Phone: 9540 8181


Sydney LHD

Phone:  1300 722 276



Sydney Children’s Hospitals Network

Phone: 9382 1055


Follow-Up Allied Health Services (Items 81300-81360)

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.


  • Aboriginal Health Worker
  • Diabetes Education
  • Audiology
  • Podiatry
  • Exercise Physiology
  • Chiropractic
  • Dietetics
  • Osteopathy
  • Mental Health Worker
  • Psychology
  • Occupational Therapy
  • Speech Pathology
  • Physiotherapy

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

CESPHN funded Aboriginal Mental Health and Social and Emotional Wellbeing Programs

Yarning Circles
A Yarning Circle is a harmonious, creative, and collaborative way of communicating to encourage responsible respectful and honest interactions between participants, building trusting relationships, foster accountability and provide a safe place to be heard and to respond.
Visit the Yarning Circle page for more information.



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:


Connector Service
The Connector Service is an Aboriginal-specific culturally safe care coordination service for Aboriginal people affected by suicide in any way. Both male and female Coordinators are available to provide support.
The service is for those who have been bereaved by suicide or those who have a recent experience of suicidality, whether it be their own experience of someone they know.

Enquiries: (02) 9699 3491 Email:


Psychological Support Services

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 – Click here

Drug and Alcohol Support Services and Programs
  • 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 DetailsAboriginal 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. Eligibility 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

Speech Pathology for Aboriginal Children (2-5 years)

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

Cultural Awareness Training

There are several resources available to assist organisations such as General Practices to assess whether their service is culturally safe. Below are resources to assist with developing a culturally safe service interested GPs and Practices.

CESPHN also facilitates regular Cultural Awareness Training CPD events for General Practitioners, Practice Nurses, Practice Staff and Allied Health Providers. Please view our events page for a list of upcoming training sessions. These events are free of charge for financial members. For more information on how to become a member see our membership page here

Useful websites and information

( * Please note– Health providers are encouraged to register to gain access to either Sydney or South Eastern Sydney HealthPathways in which a broader services directory is available).

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: 9am to 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

Ageing & Disability Commission
Address: Level 6, 93 George St, Parramatta, NSW 2150
Phone: 02 4904 7500
Hours: Monday to Friday: 9am to 5pm
Better protect older people and adults with disability from abuse, neglect and exploitation in their family, home and community.

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:

  • Lifeline Australia 131 114
  • Kids Help Line 1800 551 800
  • Suicide Call Back Service 1300 659 467
  • Care Coordinators: Vanessa Collins, Rhondda Glasson Phone: 8752 4911

Contact: Indigenous Services Unit
Phone: 9243 3429
Indigenous Call Centre: 13 63 80
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

Housing 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

Salvation Army Community Service Centre
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 NSW 2012
Target Group: Aboriginal people over 45 years and carers.
Services: Aged care services, home care and health services

Friendly Face Helping Hands
Connection Country People to City Health Services
Website on a range of city health services, programs and resources.