Chronic disease management (Integrated team care)

Having a chronic condition can be expensive, stressful and confusing. Appointments, transport, equipment and tests can be overwhelming and impossible to manage alone.

That’s where we come in.

A Chronic Condition is any medical condition lasting more than 6 months. This can include, but is not exclusive to: diabetes (and eye health conditions associated with diabetes), mental health conditions, cancer, cardiovascular disease, chronic respiratory disease and chronic kidney disease.

How can we help you?

Through our program, we offer assistance to Aboriginal and Torres Strait Islander people suffering one or more Chronic Conditions. We do this through:

Care Coordination

A care coordinator can help to organise health care relating to your chronic condition(s), such as appointments, transport, equipment and funding.

Supplementary Services

funding which can assist in paying for some appointments, equipment, services etc. relating directly to your chronic condition(s).

Where do you sign up?

Ask your GP (doctor) if they can refer you. You must be Aboriginal or Torres Strait Islander, have at least one pre-existing chronic condition and have a GP Management Plan (GPMP) formulated by your GP. Your GP must also be signed up to PIP IHI in order to refer you.


Information for GPs

How to refer a patient

GPs should complete the below referral forms and send to the relevant Care Coordinator along with a GPMP.

Bega Valley and Cooma - Monaro


Goulburn, Queanbeyan and Yass

Phone: 02 6494 8860

Phone: 02 4474 2783

Phone: 02 4287 0508

Fax: 02 6494 8855

Fax: 02 4474 0418

Fax: 02 4821 5389

    or send via Argus to





Phone: 02 4448 2203

Phone: 02 4220 7645

Phone: 02 6298 2902

Fax: 02 4448 2289

Fax: 02 4226 6489

Fax: 02 6298 2982