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Care Coordination

Integrated Team Care

Integrated Team Care supports people living with chronic disease in the Murrumbidgee region. Working with your GP, our Care Coordinators will support you to access the right health services and can provide assistance in meeting related costs.

The Integrated Team Care (ITC) program aims to improve health outcomes for Aboriginal and Torres Strait Islander people, through better access to coordinated and multidisciplinary care. By working closely with our partners we will connect you to a range of on-the-ground local support.

Marathon Health Care Coordinators will:

  • Conduct an initial assessment
  • Coordinate health care advocacy and assistance
  • Coordinate transport assistance
  • Directly engage with you and your relevant carers
  • Directly engage and case conference with your GPs
  • Liaise with other local service providers to ensure you are accessing the right services
  • Use a team based approach to your care planning

What is a chronic disease?

A chronic disease is a long lasting condition that has persistent effects. Chronic disease largely falls under six major groups: diabetes; mental health conditions; cancer; cardiovascular disease; chronic respiratory disease; and chronic kidney disease.

Where can I access ITC?

Our Care Coordinators cover a number of communities throughout the Murrumbidgee area.

How do I access ITC?

To be eligible for ITC care coordination:

  • Ensure you are enrolled for chronic disease management in a General Practice and that you have a Management Plan in place
  • Ensure you have a current Medicare card
  • Ask your GP to complete a Referral form (a copy of this form can also be accessed at Best Practice and Medical Director)
  • Forward your GP referral along with the completed Management Plan and/or Team Care Arrangement to Marathon Health (fax 1300 347 956 or email

More information 

  • Contact our referral phone line on 1300 402 585 for general queries
  • Read our ITC brochure to find out more about Integrated Team Care
  • Call us on 02 6937 2000

Marathon Health gratefully acknowledges the financial and other support from Murrumbidgee Primary Health Network through the Australian Government’s PHN Program.
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