Chronic Disease Management

Connecting you with the care you need. Coping with chronic disease and managing long-term illness can be difficult and stressful.

What is a chronic disease?

It is a disease or sickness you have lived with for a long time. Chronic diseases (or conditions) include diabetes, heart disease, kidney disease, lung (breathing) diseases, and cancer.

If you have been diagnosed with a Chronic Disease we coordinate care for clients with chronic conditions and complex needs.

The Integrated Team Care (ITC) aims to improve health outcomes for First Nations peoples who are living with a chronic disease through better access to coordinated multidisciplinary care. This is a free service available to all eligible First Nations peoples living with either cancer, diabetes, chronic respiratory, mental health, or cardiovascular disease.

ITC teams can assist with the following:

• Help to remove barriers faced by First Nations peoples with chronic conditions
• Coordinate appointments with specialists and allied health professionals
• Offer home visits and clinical outreach service, including monitoring general observations;
• Connecting and referring to support groups
• Increase uptake and ensure health assessments are current and up to date
• Provide follow-up care, including pre/post-operative care and support
• Accessing funding to pay for medical aids, including assisted breathing equipment, monitoring equipment, dose administration aids, medical footwear, mobility aids, and spectacles, in conjunction with the Medical Aids Subsidy Scheme (MASS).