Closing the Gap

Aboriginal and Torres Strait Islander people can expect to live up to 10-17 years less than non-Indigenous Australians. The health gap exists largely as a result of decades of government inaction and a continuing lack of appropriate medical services. 

The Australian Government’s National Aboriginal and Torres Strait Islander Health Plan 2013-2023 identified actions to address challenges in the current system and improve the patient journey of Aboriginal and Torres Strait Islander people.

What is the ITC Closing the Gap program?

Integrated Team Care (ITC) is one of four responses by the ‘Closing the Gap Strategy: Tackling Indigenous Chronic Disease’  developed through the Coalition of the Australian Governments and funded through the Indigenous Health Programme.

The ITC Closing the Gap Program aims to identify and contribute to improved health outcomes for Aboriginal and Torres Strait Islander people with a chronic disease by supporting them to navigate the health care system and improve access to coordinated and multidisciplinary care. 

Sonder is funded by the Primary Health Networks to deliver the ITC Closing the Gap program across metropolitan Adelaide and Yorke and Mid North South Australia. 

The Closing the Gap program is delivered by a team of Care Coordinators, Outreach Workers  and Indigenous Health Project Officers (IHPO) who contribute to closing the gap in life expectancy by improving access to culturally appropriate mainstream primary care services for Aboriginal and Torres Strait Islander people. 

Program Eligibility

To be eligible for the program, clients must:

  • Identify as Aboriginal and/or Torres Strait Islander;
  • Be enrolled for chronic disease management in a GP practice/AMS and;
  • Be unable to effectively manage their condition requiring one-on-one assistance through care coordination.

Care coordination

The Care Coordinators in the ITC Closing the Gap program are qualified health workers and registered nurses who:

  • Work with clients to assist in accessing all the care required to improve their health;
  • Help clients arrange appointmnets with doctors and other health care providers;
  • Work closely with GPs to develop treatment plans for clients;
  • Link in with other health care and support workers to make sure services are coordinated;
  • Provide clients with information about chronic conditions and other health concerns and provide them with the tools to manage their chronic diesease well enough to avoid hospitalisation;
  • Attend appointments with clients;
  • Help with medication management.

Outreach work

Closing the Gap Outreach Workers act as a link between health services and Aboriginal and Torres Strait Islander communities to break down any barriers and provide access to doctors, specialist appointments and cheaper or free medications. 

Outreach Workers can link clients to community support groups and agencies and attend appointments with health providers to make them more aware of the clients needs.

Aboriginal and Torres Strait Islander Outreach Workers:

  • Provide practical assistance to Aboriginal people to attend appointments and access health services;
  • Assist the Care Coordinators to support patients with their health assessments/care plans;
  • Establish links with local Aboriginal communities to encourage and support the increased use of health services;
  • Liaise with health providers including GPs, Aboriginal Health Workers and administrative staff to support referral pathways;
  • Develop and distribute information and resources to the local Aboriginal and Torres Strait Islander community about available health services.

Support for general practice

Our Closing the Gap team is dedicated to supporting general practices in providing quality care for their Aboriginal and Torres Strait Islander patients.

The IHPOs can assist with:

  • Sourcing appropriate resources for Aboriginal and Torres Strait Islander patients;
  • Facilitating cultural awareness training (a requirement of the PIP);
  • Navigating MBS claiming under the PIP;
  • Detailed information resources on the IHI PIP and PBS co-payment; 
  • Cultural safety audits of health services and assistance to deliver culturally sensitive and appropriate services;
  • Information on Indigenous health checks and follow-up items.

Related Resources