Integrated Team Care

The Integrated Team Care (ITC) program – formerly known as Closing the Gap (CTG) program supports Aboriginal and Torres Strait Islander people with complex chronic care needs:

  1. to improve health outcomes through better access to care and support needs
  2. to improve access to culturally relevant primary care services.
Benefits of the ITC program 

Managing long term illness can be challenging. The ITC program assists people with chronic health conditions, who need additional care from a range of health and specialised services. 

What is a chronic health condition?

A chronic health condition is an illness that last one year or more and requires ongoing medical attention for issues that limit activities of daily living, for example diabetes, heart disease, kidney disease, lung (breathing) diseases, mental health conditions and cancer. 

What ITC Services are available?
  • Care coordination support: Support for you and your doctor in line with your care plan. 
  • Education: Educational tools to help you better understand and self-manage your condition. 
  • Practical assistance: Support for you to attend appointments with health specialists and support services in line with your care plan.
  • Financial support (supplementary services): Purchasing specific equipment and medical aids (as per the ITC program guidelines) that will assist to manage chronic health conditions in line with items identified in your care plan. Click here for the ITC program guidelines.
Who is eligible to access the ITC program?

To be eligible for care coordination and supplementary services under the ITC program you must:

  1. identify as an Aboriginal and Torres Strait Islander person
  2. have a chronic health condition
  3. be registered with our practice for the Closing the Gap (CtG) Practice Incentive Program (PIP) – registration is renewed annually in November each year
  4. have a current GP Management Plan (GPMP) completed by your doctor, also known as a Care Plan
  5. have an ITC referral completed by your Doctor.

Your doctor will send all the relevant documentation to the Chronic Care Nurse who will support you to access the program services.

What is a GPMP or TCA? 

General Practitioner Management Plans (GPMPs) or Team Care Arrangements (TCAs) are written by your doctor and take approximately 45 minutes to complete.

They are a plan for you and your doctor to best manage your condition, and include referrals to specialist services and other health professionals, referrals to access medical equipment and/or aids to support the management of your chronic health condition.

What is the ITC Island to City Service?

The ITC Island to City Program supports ITC clients travelling from Palm Island to Townsville or Brisbane for health care.  It includes assistance for transport to and from medical appointments and a number of other services.

For more information please speak with the Chronic Care Nurse at the PICC clinic. 


The ITC program is fully funded by the National Aboriginal and Torres Strait Islander Health Alliance (NATSIHA).

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