Carbal Medical Services | Excellence in Aboriginal & Torres Straight Islander Health
Carbal Medical Services | Excellence in Aboriginal & Torres Straight Islander Health
Carbal Medical Services | Excellence in Aboriginal & Torres Straight Islander Health


Integrated Team Care

Home 9 Integrated Team Care (ITC)

Chronic Disease Coordination,
Outreach Worker
& Transport Services

Integrated Team Care (ITC) - Carbal Medical Services

Carbal’s Integrated Team Care, or ‘ITC’, is responsible for providing crucial support services directly to people living with complex chronic health conditions across our region.

With funding provided by the Department of Health and administered via the Darling Downs & West Moreton PHN,  ITC primarily caters to Aboriginal and Torres Strait Islander people in Toowoomba and Warwick, however our services also extend to a wider audience.

Learn how we can assist you by finding out all about our specific services below or get in touch with the team today:

‘Making a Difference’ – Carbal’s ITC Program


This short video produced by the Darling Downs and West Moreton PHN in 2019 helps provide an overview of Carbal’s role in the partnership in delivering the Integrated Team Care (ITC) program across our region.

Chronic Disease Coordination

Eligiblity & Referral

Eligible residents for Carbal’s ITC program must:

» Identify as Aboriginal and/or Torres Strait Islander.

» Have one or more of the following chronic diseases:

  • Diabetes
  • Cardiovascular disease
  • Chronic respiratory disease
  • Chronic renal (kidney) disease
  • Cancer
  • Mental Health

» Undertake a 715 Health Assessment and have a current GP Care Plan.

» Provide Consent.

» Your GP will forward a referral to the Carbal Care Coordinator and be informed every step of the way as to outcomes achieved.

Role of the Care Coordinator

Carbal’s team of care coordinators are professional, qualified health workers who are dedicated to improving the ongoing quality of life conditions of their clients by:

» Assisting you to understand your chronic health condition and how to manage it on a daily basis.

» Advising you about the importance of following your care plan and support you with achieving desired outcomes.

» Arranging health service appointments when required.

» Reminding you to attend regular review appointments with your GP and other health related appointments.

» Providing support to identify signs and symptoms that your condition may need further management.

Supplementary Services

At the discretion of the GP Care Plan, funds may be allocated to support a client’s care and advance their health outcomes from time-to time.

The Care Coordinator in line with federal guidelines can approve expenditure such as:

» Fees for services by allied health providers (where Medicare rebates are not available, e.g. no bulk billing option).

» Paying the difference between the Medicare rebate and fees charged (gap payment) by specialist and allied health providers.

» Paying a specialist a retainer for making an urgent appointment.

» Organising transport or the payment of associated transport costs to medical appointments.

ITC Outreach Worker


Referrals for this service can be provided by any stakeholder who identifies the need for transport. This service also accepts self referrals.


Eligible clients must:

  • Identify as Aboriginal and/or Torres Strait Islander;
  • Provide consent;
  • Require transport to a medical appointment or to access to medical facilities.


Patients will be prioritised due to availability of the Outreach Worker.

Transport Services - Integrated Team Care (ITC) - Carbal Medical Services


Carbal is able to provide transport to and from medical appointments for all eligible clients, however please be advised that a minimum of 24 hours notice is required to be given prior to the appointment time.

Current clients can organise their transport booking by phoning one of Carbal’s Transport Officers directly during clinic hours:

James Gilroy
📱 | 0438 913 710

William Callaghan
📱 | 0487 200 003

ITC Success Stories

“My client was referred to Carbal’s ITC program for Chronic Respiratory Disease and the referring doctor was wanting us to assist them with having a sleep study conducted.

The client was astounded with his sleep study results with 8 apnoea and 163 hypopnea events recorded during one night’s sleep; from which his doctor was able to diagnose that his ongoing issues had been connected to severe obstructive sleep apnoea.

Carbal’s ITC program was able to cover all the associated costs for providing a CPAP machine, resulting in a much better quality of living by allowing him to sleep easily much more consistently.

Our client was so appreciative of the assistance that Carbal’s ITC program had provided, that he even insisted on going out of his way to shout the entire ITC team morning tea!”

Rebecca Bennett

Rebecca Bennett

ITC Care Coordinator, Toowoomba

"One of my clients was referred to Carbal's ITC for cancer, mental health and cardiovascular disease in addition to almost two dozen debilitating chronic health issues.

Naturally this has had a massive effect on her and her husband's mental health, due to trying to manage these multiple conditions, struggling financially trying to pay for the multiple specialist, allied health, medical equipment, mediations and dressing, etc.

Since Leah needs full time care, her husband had to give up work to look after her, which put more stress on them financially and had almost completely left her incapacitated; hardly able to leave her bed or even her home.

ITC has been able to relieve some of the financial burden and stress by covering the costs of her specialist consultations, including neurology and PlantMed for pain treatment, and allied health appointments. ITC are also assisting with the costs of the many medical supplies that she needs each month including syringes, masks, dressings, etc. ITC has also supplied her with a raised toilet seat to make life a bit easier.

I have also ensured that my client has become linked in with Carbal’s Outreach Health Suppoert Service team to assist with the Centrelink issues that she and her husband are having as a result of their circumstances.

I have regular contact with her through emails, texts and phone calls and she is always very appreciative for all of the assistance that ITC has provided to assist in improving her quality of life."

Toni Crossley

Toni Crossley

ITC Care Coordinator, Toowoomba

“I have been on the outside looking in for a few years handling the financial side of things relating to Carbal’s ITC service and even though I have only been working as an ITC Care Coordinator in Warwick for a few months, I have already experienced the positive change that we are able to make in the lives of our clients.

We are also noticing an increase in the volume of Indigenous community members engaging with the program.

Our clients are always thankful for the service we provide and are up for a yarn; I feel like I'm making a positive change in their day-to-day lives and they are wanting to engage more and improve their health. This position has been extremely rewarding for me.”

Nikole Ballai

Nikole Ballai

ITC Care Coordinator, Warwick
Integrated Team Care (ITC) - Carbal Medical Services

Contact Carbal’s ITC Team

All enquiries related to ITC can be directed to Carbal’s dedicated team based at Charnley Street.

If you have a non-urgent general enquiry, you can now get in touch by sending us an online message:

Integrated Team Care (ITC) - Carbal Medical Services

Carbal ITC
– Integrated Team Care


18-24 Charnley Street

Kearneys Spring QLD 4350


Opening Hours:

Mon-Fri: 8:30AM – 4:30PM



(07) 4633 9500

Carbal's Integrated Team Care | 18-24 Charnley Street, Kearneys Spring

Online Enquiries

Do you have an enquiry related to Carbal’s Integrated Team Care services?

We’d love to hear from you!

Please submit your details and a member of our ITC team will be in touch to discuss further with you.

Integrated Team Care (ITC) - Carbal Medical Services