Services and support
Integrated team care program
Helping Aboriginal people with chronic conditions stay connected to care and community.
The Aboriginal Medical Services Alliance Northern Territory (AMSANT) integrated team care program supports Aboriginal community controlled health services (ACCHSs) and their chronic disease care coordination teams across the Northern Territory.
What we do
The integrated team care program supports the workforce that delivers chronic disease care coordination in ACCHSs and other commissioned ITC services. AMSANT provides mentoring, visits and practical tools for care coordinators, nurses, Aboriginal health practitioners, social workers and outreach workers.
We help services strengthen their care coordination models, connect ITC workers across the Northern Territory, and link teams into training, communities of practice and resources grounded in Aboriginal community-controlled health.
Why this program matters
Many Aboriginal people in the NT live with more than one chronic condition, often while juggling housing, transport, income and caring responsibilities. Managing appointments, medications and referrals across different services can be stressful and confusing.
Care coordination led by ACCHSs makes this journey safer and more culturally secure. The ITC program strengthens the workforce and systems that support people to understand their conditions, navigate the health system and, where possible, stay out of hospital.
Our focus areas
The program focuses on building a strong, connected and culturally competent ITC workforce. This includes supporting good chronic disease care coordination practice, Aboriginal leadership within teams, and solid working relationships between ACCHSs, Northern Territory Primary Health Network (NT PHN) commissioned providers and mainstream services.
We also share good practice across services and make sure workforce development, supervision and tools for workers are realistic for remote, regional and urban settings.
How we support member services
We liaise with member services about how integrated team care is working locally—what is going well, what is hard for staff and clients, and what support is most needed. From there, we offer tailored workforce support such as visits, joint planning, mentoring for care coordinators and Indigenous health project officers, and links to training or communities of practice.
We also help services think through team roles, referral pathways and relationships with general practitioners and specialists, and advocate with partners so program design and reporting better reflect the realities of delivering ITC in Aboriginal community-controlled settings.
Who we work with
The integrated team care program works with ACCHSs delivering chronic disease care coordination and outreach. This includes care coordinators, Aboriginal health practitioners, nurses, social workers, outreach workers and Indigenous health project officers, as well as service managers and clinical leaders responsible for chronic disease programs.
We also collaborate with partners such as the NT PHN, mainstream primary health care providers, specialists and allied health services involved in integrated team care arrangements.
Our impact
Through the integrated team care program, AMSANT is helping services and workforce to:
- strengthen chronic disease care coordination practice within ACCHSs
- improve communication between care coordinators, outreach workers, general practitioners, specialists and allied health providers
- increase workforce confidence in navigating health and social systems with clients
- support better access to culturally safe care, follow-up and self-management support for Aboriginal people with chronic conditions.
Over time, this helps reduce avoidable hospitalisations, improve health outcomes and support people to live well with chronic conditions on their own country.
Current projects & initiatives
ITC workforce support and mentoring
ongoing support for care coordinators, outreach workers and Indigenous health project officers through mentoring, visits and regular contact.
Integrated team care communities of practice
spaces for ITC workers to talk together, share stories and learn from each other’s approaches.
Chronic disease care coordination tools and resources
practical templates and client resources that services can adapt to local languages and systems.
Partnership work with commissioning bodies and mainstream services
working with the NTPHN and other partners to strengthen program design, reporting, referral pathways and workforce support.
Resources & downloads
Program overviews and referral information, tools and resources for care coordinators and outreach workers, chronic disease self-management resources for clients and families, and information about communities of practice and training opportunities are available.