Complex chronic disease care coordination
The
Integrated Team Care (ITC) program supports Aboriginal and Torres Strait Islander people with chronic diseases, particularly those who require complex care assistance from allied health and specialist services.
SEMPHN commissions the
Dandenong and District Aborigines Co-operative Limited (DDACL) and
Better Health Network (BHN) to develop, implement and administer the program with community. DDACL is an Aboriginal Community Controlled Health Service (ACCHS), and ITC is delivered by a team of Indigenous health project officers, Aboriginal and Torres Strait Islander outreach workers, and care coordinators.
ITC’s main functions involve coordinating care for patients, helping them to access funds for urgent or essential health services where needed, and empowering them to manage their health. ITC’s Indigenous health project officers also develop and implement strategies to support primary care providers in delivering culturally safe healthcare, coordinate cultural competency training, and identify and address barriers faced by Indigenous people when accessing mainstream services.
The program’s client-centred approach and strong advocacy for culturally appropriate care underpins its success.
“This helps ensure clients feel safe and supported across mainstream services,” says SEMPHN Program Officer Alex Towner. “Both care coordinators and outreach workers have emphasised the profound impact of establishing trust and rapport with clients, particularly those with complex or traumatic histories.”
In 2024–25, ITC delivered more than 6,500 services to 161 clients, including 67 new patients, with the support provided ranging from clinical assistance to care coordination. During the year, program staff also engaged local Aboriginal Gathering Places, including at Nairm Marr Djambana, Derrimut Weelam, and in the City of Casey.
“This has supported service awareness, trust building, and maintenance of community relationships,” says Alex.
Cancer screening education and support
SEMPHN also commissioned DDACL and BHN to deliver the First Nations Cancer Screening Program (FNCSP), which aims to increase breast, cervical and bowel cancer screening among First Nations peoples.
One key way in which the program achieves this is by increasing awareness and understanding of the importance of cancer screening among community members. In 2024–25, the DDACL FNCSP team engaged the community through various health promotion events, including NAIDOC Family Day in July 2024, the Bay Mob Expo in September 2024, Close the Gap Day in March 2025, Bowel Cancer Awareness Day in June 2025, and information sessions throughout the year.
Alex says the FNSCP team was able to connect with 70 First Nations people at NAIDOC Family Day, and a further 40 community members at the Close the Gap Day event.
“These gatherings are an important opportunity for open discussions about health issues in a culturally safe space,” says Alex. “We had a number of people express their interest in cancer screening after these events, demonstrating the FNSCP team’s success in educating the community on the importance of early detection and prevention.”
Another way in which FNCSP supports cancer screening is by providing community members with practical support for attending cancer screening appointments. Based on available data, the program directly supported at least 64 cervical cancer tests and 98 breast cancer screenings in 2024–25.
BHN’s cancer screening program concluded on 30 September 2025, and DDACL’s program ends on 31 December 2025.
Youth mental health outreach
Mental health is another key focus for SEMPHN’s First Nations health commissioning activity, being the most common chronic condition in south east Melbourne’s First Nations population.
SEMPHN commissions DDACL to provide youth mental health services aimed at reaching out to socially isolated and disengaged Aboriginal and Torres Strait Islander youth and helping them to navigate the mental health system in the local government areas of Dandenong/Casey and Frankston/Mornington Peninsula.
DDACL has sub-contracted
YSAS to run these services in collaboration with
headspace Frankston and Dandenong. Each headspace centre has an Aboriginal youth worker that provides culturally appropriate mental health support.
The youth workers provide one-on-one support at their headspace centres, via telehealth, or through outreach, visiting young people in their community. They also run group support programs, which can include activities such as art and music therapy, and helping to build cultural community spaces, depending on the participating individuals’ needs.
In 2024–25, headspace Frankston and Dandenong supported 53 Aboriginal and Torres Strait Islander young people. The Aboriginal youth workers and their teams were also heavily involved in community outreach throughout the year, including participating in community health and wellbeing events, and engaging schools, local Gathering Places and other First Nations organisations to establish referral pathways.
