Authors: Kylie Falciani
The national Integrated Team Care (ITC) program supports First Nations people who live with chronic diseases and have complex healthcare needs. Marathon Health delivers ITC on behalf of the Murrumbidgee PHN – working closely with Aboriginal Medical Services (AMS), allied health practitioners, medical specialists, public and private GPs, and the Murrumbidgee Local Health District.
The program takes a team-based approach to care planning, with 10 Care Coordinators (40% who identify as First Nations) whose role is to work with participants to:
- Coordinate care and services
- Improve and support self-management and health literacy
- Ensure the participant is at the centre of a team-based and empowering approach to their care planning, with their GP and other relevant members of the broader health care team.
The team is also working with more than 40 GP and AMS clinics across the Murrumbidgee to build the capacity of staff to deliver culturally safe and appropriate services, in a bid to reduce unnecessary hospital admissions. Last financial year, we supported 297 clients and delivered 8,600 occasions of service through ITC.
Outcomes are strong, with high numbers of ITC participants existing from the program with health care management plans in place and high levels of self-reported client improvements.
Of the 50 participants who completed the client survey in 2023:
- 98% agreed that their health and wellbeing had improved since taking part in ITC
- 84% showed better health outcomes on the Partners in Health (PIH) scale
- 87% had a GP management plan or team care arrangement in place on exit
- 64% had a self-management plan in place on exit.
Marathon Health and the ITC program are working with the community to reduce health inequities for First Nations people through:
- Working with communities to address Closing the Gap life expectancy targets
- Reducing barriers to accessing our services
- Improving client understanding of the health system, their chronic condition and treatments, and how to manage their own health
- Educating GPs and allied health practitioners in delivering culturally-safe services
- Increasing First Nations representation through our Aboriginal and Torres Strait Islander Workforce Development Plan.