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Closing the Gap – Integrated Team Care

Free support for Aboriginal and/or Torres Strait Islander people to better manage chronic conditions.

Get support to better manage your chronic condition and live a better, healthier life.

If you have a chronic condition, such as cancer, diabetes, kidney disease, heart disease and/or lung disease, our team can help you to manage your condition so you can stay healthy and strong for your family and community.

Our program adopts a team-based approach. Outreach Workers and Care Coordinators will work with you to support you in accessing medical care and other culturally appropriate health and community services.

Working together, our team can help you to develop self-management skills to better manage your chronic condition and live a healthier life.

What do we offer?

  • Help to better understand your chronic condition

    Care Coordinators will work with you to help you to understand your chronic condition and what it means for you.

  • Access to specialist doctors and allied health services

    We'll support you to access medical care and other culturally appropriate health and community services.

  • Help with transport to your medical appointments

    We provide short-term transport assistance to medical appointments and will be there with you for support during your appointment.

  • Links to community supports

    We'll help you to connect to ongoing community supports e.g. home care services who can provide assistance to improve your physical health and wellbeing.

Accessing this service

Am I eligible?

To be eligible for the program, you must:

  • Identify as Aboriginal and/or Torres Strait Islander;
  • Be enrolled for chronic disease management in a GP Practice, Aboriginal Health Service and;
  • Be unable to effectively manage your chronic condition.

Who are the Closing the Gap program staff?

This program is provided by a team of Aboriginal Outreach Workers, Care Coordinators and Indigenous Health Project Officers.

Care Coordinators work to help you understand your chronic health condition and how to manage it by following your GP management plan.

Outreach Workers help you to make better use of available healthcare services by providing practical assistance to access services and attend appointments.

How do I access the service?

This program is available for people living in metropolitan Adelaide, Gawler-Barossa, Yorke Peninsula & Mid-North South Australia.

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.

If you do not have a regular GP, contact us at (08) 8209 0700 or email info@sonder.net.au and we’ll help you to access the service.

Contact Us


Hear from our clients

Information for GPs

To refer a patient to this program, complete a Closing the Gap Referral Form and a GP Management Plan and fax or email to us.

Referral form

Am I at risk of developing a Chronic Disease?

As an Aboriginal or Torres Strait Islander person, you may be at higher risk of developing a chronic disease.

Better management of chronic disease is a key factor in meeting the target of closing the gap in life expectancy between Aboriginal and non-Aboriginal Australians.

Frequently Asked Questions

Information for general practices

Get support at your general practice

Looking to deliver better Aboriginal services at your general practice? Get in touch with our Indigenous Health Project Officer and find out how we can help.

Contact us

Volunteer with us

Our Aboriginal Health Reference Group provides a voice to Aboriginal Health consumers, their relatives, significant others and carers. Members have the opportunity to provide input and feedback to improve the health outcomes of the Aboriginal community

Find out more

This service is supported by funding from Adelaide PHN and Country SA PHN through the Australian Government’s Primary Health Network Program.