Chronic Disease Management (Integrated Team Care)

Free care coordination services for Aboriginal or Torres Strait Islanders 16 years and over in Southern NSW. This program is suitable for clients with chronic and complex health conditions such as Diabetes, Heart Disease and Respiratory Disease.

Referral form


Fact sheet for GPs

Referral information

To qualify for this program 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.

GPs are to complete the referral form and send to the relevant Care Coordinator office 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: 0408 725 319

Phone: 02 6298 2902

Fax: 02 4448 2289

Fax: 02 4226 6489

Fax: 02 6298 2982

From February 1 2021 Grand Pacific Health will no longer be accepting referrals to the Connecting Care in the Community Program, as the service has transitioned to the Local Health District.
For further information please contact the Access and Referral Centre at the Illawarra Shoalhaven Local Health District on 1300 792 755