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Overcoming health challenges with integrated care

Overcoming health challenges with integrated care

Mariah’s story

Mariah’s story is a testament to resilience and the power of integrated, comprehensive, and compassionate care. Overwhelmed by complex medical conditions and frequent hospital admissions, Mariah sought help from her GP, who referred her to the Closing the Gap – Integrated Team Care (CTG ITC) program.

The CTG ITC program supports Aboriginal and/or Torres Strait Islander people in managing chronic health conditions through personalised care coordination, self-management skill development, and practical assistance to access necessary services.

Mariah’s primary goal was to manage her health more effectively, especially her type 1 diabetes and recently diagnosed Charcot foot, which had been casted, making her unable to weight bear. She faced continual health issues, including fortnightly hospital admissions for vomiting and diabetic ketoacidosis, mental health challenges, frequent infections, missed insulin treatments, diabetic autonomic neuropathy causing hypotension and dizziness, and gastroparesis. Mariah also suffered from osteoporosis, which led to bilateral leg fractures with poor healing, chronic pain, and decreased mobility.

The complexity of her health issues were significant barriers that she struggled to overcome on her own. Sonder’s CTG ITC team supported Mariah to purchase a knee walker to aid her mobility, setup a Webster-pak for medication management, and arranged appointments for the services outlined on her GP Management Plan, including gastroenterology, dental care, ophthalmology, orthopaedics, and diabetes care (endocrinology, diabetes education, and dietetics). They also arranged transport to and from these appointments where needed, ensuring Mariah could access the care she needed without any logistical or financial barriers.

Coordination with other services, such as Aspire, was also crucial in supporting Mariah with applications for the Disability Support Pension (DSP) and National Disability Insurance Scheme (NDIS) to enable her to access additional supports.

Nicola, Mariah’s Care Coordinator in the CTG ITC program, played a pivotal role in her journey. Nicola shared,

“Mariah’s determination to improve her health despite the overwhelming challenges has been inspiring. Our team has been committed to providing the necessary support and encouragement to help her achieve her goals,”

Support from Mariah’s stepmother, counsellors, and various hospital teams complemented the comprehensive care plan put in place by Sonder. Through meticulous planning of her appointments and continuous encouragement, advocacy and education, Mariah gradually began to manage her health more effectively.

Mariah expressed her gratitude for the support she received, saying,

“I would like to thank Sonder and everyone on the team for their support, advocacy, encouragement, and care. Helping me to get back on track with my health and wellbeing. To have real people who genuinely care and understand my situation has been a blessing. Thank you for always checking in on me.”

Mariah’s journey highlights the importance of integrated care and the positive impact it can have on individuals facing complex health challenges. With the comprehensive support of Sonder’s CTG ITC program, Mariah has been able to reclaim control over her health and improve her quality of life.


Looking for support?

To get started, make an appointment with your regular GP or Aboriginal Health Worker, and ask them to complete an Aboriginal Health Check and/or a GP Management Plan and make a referral to Sonder for the Closing the Gap ITC program.

If you do not have a regular GP, contact us and we can support you to access the service. Call (08) 8209 0700 or email info@sonder.net.au to chat with our friendly team.


Closing the Gap Integrated Team Care is supported by funding from Adelaide PHN and Country SA PHN through the Australian Government’s Primary Health Network Program.