The Practice Incentive (PIP) Indigenous Health Incentive is aimed at supporting general practice, as well as Aboriginal health services to provide a comprehensive range of health services to Aboriginal people with chronic health problems. Financial incentives are arranged into 3 components that are based upon the level of care provided. Practices participating in the incentive will also have increased access to supporting health services for their patients. More information on the PIP Indigenous Health Incentive can be accessed at:

• PIP Indigenous Health Incentive Guidelines
• Practice Incentives Programs website

Practices registered for the Indigenous Health Practice Incentive Program

For clinics wishing to provide us information on their PIP IHI registration status and/or consent for us to provide this information on website below please complete form HERE.

Please select the first letter of a suburb that is nearest to you: A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Background

From 2016-17, the Improving Indigenous Access to Mainstream Primary Care (IIAMPC) activities and the Care Coordination and Supplementary Services (CCSS) have been combined to form the Integrated Team Care (ITC) Activity.

ITC Activity is one of the measures under the Closing the Gap scheme aimed at improving chronic disease management for Aboriginal and Torres Strait Islander people. ITC includes Care Coordination, Supplementary Services and Outreach Work. 

Care Coordination 

Care Coordination is provided by a qualified healthcare worker to Aboriginal and Torres Strait Islander people with a chronic condition such as respiratory disease, renal disease, cardiovascular disease, diabetes or cancer.

Care Coordinators are qualified health workers (for example, nurses, Allied Health professionals or Aboriginal Health Workers) who support eligible patients to access the services they need to treat their chronic disease according to the General Practitioner (GP) care plan.

The work of a Care Coordinator can include providing clinical care, arranging the services in patients’ care plans and assisting patients to participate in regular reviews by their primary care providers. Care Coordinators work closely with Aboriginal Outreach Workers in many of these activities.

Care coordinators who will work collaboratively with GPs in accordance with the client’s care plan. The care coordinators may assist clients in a number of ways: 

• assist people in understanding their chronic health condition and help them to develop self-management skills
• assist with understanding of medicines
• assist with lifestyle changes and referrals to programs to assist
• facilitate connections to other community support services
• organise appointments and/or transport with appropriate services; and
• advise on the importance of following care plans, for example assisting patients to participate in regular reviews with their GP or recommended follow up appointments with allied health or specialists.

Supplementary Services 

ITC has a flexible pool of funds that can be used to assist clients receiving care coordination. The funds can be used to improve access to medical specialist and Allied Health services that are in accordance with the client's GP care plan.

Care Coordinators have access to a Supplementary Services Funding Pool when they need to expedite a patient’s access to an urgent and essential Allied Health or specialist service, or necessary transport to access the service, where this is not publicly available in a clinically acceptable timeframe.

The Supplementary Services Funding Pool can also be used to assist patients to access some GP approved medical aids.

Outreach Work

Outreach Workers are a component of the ITC Program to encourage Aboriginal and Torres Strait Islander people to access health services and help to ensure that services are culturally competent. They have strong links to the community they work in.

The Aboriginal Outreach Worker provides non-clinical services including the following:

• Information and resources about locally available health services
• Referrals to culturally appropriate health care providers and services
• Information and assistance with travel options to and from health appointments
• Support when attending health appointments, including; GPs, specialists, allied health providers and diagnostic tests
• Assistance with effective communication between yourself and the health care provider
• Information about local community services and activities

ITC Activity is provided by South Eastern Sydney LHD, Sydney LHD and Sydney Children’s Hospitals Network. All services provided through ITC are funded through CESPHN, and there are no direct costs to patients.

For more information about ITC

South Eastern Sydney LHD

Phone: 9540 8181

Email: seslhd-seahc@health.nsw.gov.au

Sydney LHD

Phone:  1300 722 276 

Email: SLHD-ACTCallCentre@health.nsw.gov.au

Sydney Children’s Hospitals Network

Phone: 9382 1055

Email: SCHN-SCH-CARPAHeads@health.nsw.gov.au

Available to any Aboriginal and/or Torres Strait Islander patient who has received a health check, and the need for Allied Health Services was identified. Maximum 5 services per year.

Includes:

• Aboriginal Health Worker
• Diabetes Education
• Audiology
• Podiatry
• Exercise Physiology
• Chiropractic
• Dietetics
• Osteopathy
• Mental Health Worker
• Psychology
• Occupational Therapy
• Speech Pathology
• Physiotherapy

Referral to Allied Health for Follow Up Services for Aboriginal and Torres Strait Islander people Factsheet
Follow-up Allied Health Services for People of Aboriginal and Torres Strait Islander Descent (MBS Items 81300-81360) Fact Sheet

Referral to Allied Health Template
Indigenous follow up referral form

Connector
The Connector service provides culturally safe support and care coordination to Aboriginal and/or Torres Strait Islander people or groups in the region who have experienced a recent suicide or suicide attempt either themselves or of someone they know.
Visit the Connector page for more information.

Yarning Circles
A Yarning Circle is a harmonious, creative, and collaborative way of communicating to encourage responsible respectful and honest interactions between participants, building trusting relationships, foster accountability and provide a safe place to be heard and to respond.
Visit the Yarning Circle page for more information.

Youth Health and Wellbeing Program - La Perouse
Perouse Local Aboriginal Land Council has two Health and Wellbeing Coordinators to engage with and support young people aged 12-25 years. Coordinators help young people access culturally appropriate mainstream services to address their health and wellbeing needs.
Enquiries: 9311 4282 Email: admin@laperouse.org.au

Youth Outreach Program
headspace Ashfield provides outreach support and link Aboriginal and/or Torres Strait Islander young peoples to local and culturally appropriate services and programs.
Enquiries: 9193 8000 Website: www.headspace.org.au/headspacecentres/ashfield/

Youth Health and Wellbeing Program - Inner City
Tribal Warrior Aboriginal Corporation has two Health and Wellbeing Coordinators to engage with and support young people of all ages. Coordinators help young people access culturally appropriate mainstream services to address their health and wellbeing needs.
Enquiries: 9699 3491 Email: info@tribalwarrior.org

Psychological Support Services

PSS provides FREE short-term face to face psychological services for underserviced groups. Services are delivered by appropriately trained and qualified mental health professionals including: Psychologists (general and clinical), mental health nurses, mental health accredited social workers, mental health accredited occupational therapists and Aboriginal and Torres Strait Islander mental health workers. To find out more – Click here

• Weave Youth and Community Services: 'Speak Out' Dual Diagnosis ProgramCare coordination, counselling, information and referral support and group activities for young people with mental health and drug and alcohol support needs. Drop-in centre.
  Enquiries: 9318 0539 Website: www.weave.org.au
• Drug and alcohol program – Community Restorative Centre
  
  Provides holistic outreach-based rehabilitation to support community reintegration on release from custody. Accessible via a Service and Programs Officer (SAPO), parole officer or case-manager. Enquiries: 9288 8700 Website: www.crcnsw.org.au
• Redfern Aboriginal Medical Service (AMS) Drug and Alcohol Treatment Program
  
  What is the AMS Drug and Alcohol Treatment Program?
  
  The Aboriginal Medical Service (AMS) Drug and Alcohol Treatment Programme provides culturally appropriate non-residential treatment programmes, pharmacotherapies, counselling, referral services and aftercare.

The AMS provides a range of services including:

• Client focused health promotion including harm minimisation advice
• Infectious disease screening and contact tracing
• General primary medical care
• Counselling for drug and alcohol issues
• Methadone maintenance and buprenorphine out-patient detoxification and maintenance pharmacotherapy treatment programs
• Outpatient rehabilitation services
• Outreach counselling
• Referral services
• Dual diagnosis management in conjunction with AMS general medical, psychiatry and psychology clinics

Eligibility

• Aboriginal and Torres Strait Islander people that are registered patients/clients of the service and their families.
• Clients over 18 who present with substance use.

How to access the service?Self-referral or via an allied health service.Contact DetailsAboriginal Medical Centre
Drug and Alcohol Treatment Program
36 Turner Street, Redfern, NSW 2016. 
Phone: (02) 93195823
Website: http://amsredfern.org.au/

• We Help Ourselves (WHOS) withdrawal management

What is the Withdrawal Management service?WHOS deliver an innovative community based ambulatory model of Withdrawal Management care for low-to-moderate withdrawal needs. This service is based at the WHOS Rozelle site for people who present for admission to the WHOS Residential Programs. It provides clients with support for detoxification before entering further treatment with WHOs, within a community-based environment with access to support from the existing day programs.CESPHN also fund identified Aboriginal and Torres Strait Islander Engagement Officer positions at WHOs, who work across the day residential programs to provide culturally appropriate support.EligibilityClients will be assessed for suitability to the WHOS Withdrawal Management program or may be referred for hospital detoxification.How to access the service?Self-referral, via an allied health service, by application from a general practitioner working in collaboration with SLHD or SESLHD departments/detoxes or a WHOS nurse.Contact DetailsPhone: (02) 85727444Service Manager: Carolyn Stubley (Nurse Manager) WHOS: 8572 7471
Website: https://whos.com.au/

• Odyssey House

What is Odyssey House Community Services (OHCS) and who can use it?Odyssey House Community Services delivers a range of free alcohol and other drug (AOD) services within a holistic stepped care treatment model. The model includes aftercare support, psychosocial counselling for individuals with co-occurring substance misuse and mental health (MH) disorders with access to individual care co-ordination and counselling. Programs are flexible, evidence based, client centred, and aim to achieve positive client outcomes through an integrated approach and include:

• Aftercare
  The Odyssey House Community Services Aftercare services are designed as a two stage AOD recovery program that a client can access at either the commencement of their treatment journey or at the end of their time in a residential AOD service or for support post relapse. The model is designed to be responsive to client needs such as education regarding substance misuse, providing relapse prevention education and care coordination that will assist with other issues such as housing, unemployment, money management and health or mental health issues. The Aftercare AOD Recovery Groups provide an accessible treatment option for clients who are under the supervision of Community Corrections or are currently engaged in a MERIT Program.
• Psychosocial Counselling
  The psychosocial counselling services can be delivered in conjunction with aftercare services and aim to equip clients with co-occurring Alcohol and other drugs (AOD) and Mental Health (MH) issues with therapeutic tools which will support and sustain their recovery. There is a Mental Health Recovery group program run over 8 weeks which is focussed on supporting clients through their treatment journey and developing strategies to build resilience and wellbeing.

Clients can also access one on one support through counselling with qualified clinicians.All services are free and a Mental Health Care Plan is not required.The Aboriginal and Torres Strait Islander Program, which includes partnerships with Aboriginal organisations and aims to deliver AOD and Wellbeing Men’s and Women’s groups.Eligibility

• Current alcohol and/or other drug dependency or history of;
• Residing in the Central and Eastern Sydney PHN region
• 18 and over for all programs
• Under 18 can access for counselling only

How to access the service? Contact Odyssey House directly 1800 397 739 Website https://www.odysseyhouse.com.au/what-we-do/community-services/

The Sydney Children’s Hospital (SCH) offers an Aboriginal focused speech pathology service, which aims to deliver flexible and culturally appropriate services to Aboriginal Children and their families. For more information, please contact: 9382 1021

There are several resources available to assist organisations such as General Practices to assess whether their service is culturally safe. Below are resources to assist with developing a culturally safe service interested GPs and Practices.

• Cultural Awareness Self-Assessment Toolkit - ACT Council of Social Service Inc
• Working with Aboriginal people and communities: Health and community services audit - Making Two Worlds Work

CESPHN also facilitates regular Cultural Awareness Training CPD events for General Practitioners, Practice Nurses, Practice Staff and Allied Health Providers. Please view our events page for a list of upcoming training sessions. These events are free of charge for financial members. For more information on how to become a member see our membership page here 

( * Please note- Health providers are encouraged to register to gain access to either Sydney or South Eastern Sydney HealthPathways in which a broader services directory is available).

Aboriginal Employment Strategy
Address: 1-9 Glebe Point Rd Glebe.
Phone: 8571 0999
Services: A not-for-profit organisation that specialises in placing and mentoring Aboriginal people into employment

Aboriginal Health and Medical Research Council
Phone: 9212 4777
Address: Level 3, 66 Wentworth Avenue SURRY HILLS NSW 2010
Area Served: NSW
Services: Advisory service on Aboriginal health and medical services, community information.

Aboriginal Medical Service
Address: 36 Turner Street REDFERN NSW 2016
Phone: 9319 5823
Email: amsredfern@amsredfern.org.au
Hours: Monday to Thursday: 9amto 6pm & Friday: 10am to 5pm
Services: Counselling, diabetes, HACC services, HIV/AIDS, sexual assault, health education, aged care services and Aboriginal health services.
Target Group: Aboriginal and Torres Strait Islanders, Addicts, Carers, People with Disability, Housebound, Older People

Australian Indigenous HealthInfoNet
The Australian Indigenous HealthInfoNet is a web resource that informs practice and policy in Indigenous health by making research and other knowledge readily accessible. The HealthInfoNet is not a provider of health services, nor does it provide crisis support. If you require urgent help, please contact: 

• Lifeline Australia 131 114
• Kids Help Line 1800 551 800
• Suicide Call Back Service 1300 659 467
• Care Coordinators: Vanessa Collins, Rhondda Glasson Phone: 8752 4911

Centrelink
Contact: Indigenous Services Unit
Phone: 9243 3429
Indigenous Call Centre: 13 6380
Address: 140 Redfern Street REDFERN NSW 2016
Services: Advocacy, support for Centrelink Indigenous clients in the East and Western areas of Sydney to access to: education, employment and training. Community, engagement and building partnerships.

Community Health Centre - Redfern
Phone: 9515 3150
Contact: Aboriginal Health Worker, Community Nursing
Address: Redfern Community Health Centre, 1 Albert St, Redfern
Services: Generalist community nursing providing assessment, referral and direct care services to people in their own homes.

First Peoples Disability Network Australia (FPDN)
Phone: 8399 0882
Address: 402/161 Redfern St, Redfern
Services: Brings together Aboriginal and Torres Strait Islander people in an attempt to address the high degree of unmet need for Aboriginal people with a disability.
Area Serviced: NSW

Housing NSW
General Inquiries 24 hr on 1300 468 746
Target Group: Low income earners, pensioners and people with disabilities from18 years who are unable to secure and retain accommodation in the private market

Address: Level 7, 52 Railway Parade, Burwood
Phone: 8372 4700

Address: Ground Floor, 219- 241 Cleveland Street, Redfern
Phone: 9268 3444

Housing Pathways NSW
Temporary Accommodation Line: 1800 155 152
Aboriginal Housing Information Service: 1800 727 555

Salvation Army Community Service Centres
Address: 30 Anglo Road, Campsie
Phone: 9787 2333

The National Aboriginal Community Controlled Health Organisation (NACCHO)
Office: 221 London Circuit Canberra City ACT 2601
Postal:  PO Box 5120 Braddon ACT 2612 
Phone: 6246 9300
Fax: 6248 0744

Wyanga Aboriginal Aged Care Program
Contact: Client Services Officer
Phone: 9319 7175
Address: 33 Cope Street REDFERN NSW2012
Target Group: Aboriginal people over 45 years and carers.
Services: Aged care services, home care and health services

Aboriginal and Torres Strait Islander health assessments - barriers to improving uptake

 Kehoe, H., Lovett, R. W. 2008

 Friendly Faces Helping Hands

Connecting Country People to City Health Services

Website on a range of city Health services, programs and resources.