Integrated Team Care Program – Interview with Mary Anne Johnston

09 July 2021


Mary Anne Johnston works as a Community Nurse in our Integrated Team Care Program, which supports the health and wellbeing of Aboriginal and Torres Strait Islander peoples living with chronic conditions. We spoke to Mary Anne to find out more about the work of the program, and why culturally safe and respectful health care services are so important.

What is the Integrated Team Care Program?

The Integrated Team Care (ITC) Program is designed to support people from Aboriginal and Torres Strait Islander backgrounds who have chronic health conditions. The main conditions we focus on are cancer, cardiovascular disease, diabetes, renal diseases, respiratory diseases and mental health. The program connects clients with services to help them manage their condition/s, and aims to reduce Emergency Department presentations and hospitalisations for people living with chronic conditions.

What is your role in the Program?

I work as a Community Nurse in the Program. My role is to advocate for my clients and help them to connect with services they need when they’re ready to, in a way that is culturally safe and appropriate for them. While the physical and mental health of clients is a key focus, we also understand how important connection to culture and community is for a client’s overall wellbeing, and aim to support these connections when linking them to services.

How does the ITC Program support clients in a way that is culturally safe and respectful?

We always try to ensure our clients to feel culturally safe and respected and this starts at our initial meeting, when the client can tell as little or as much of their story as they feel comfortable. This can take some time and we allow for this. Conversations are important; listening and ensuring the client has been able to have their wishes heard and acknowledged empowers them to feel more engaged with their health care provider.

It can be important for a client to have their family members involved with their care and appointments, and once again the client should be in charge of who is involved and to what extent. If the client attends appointments at healthAbility, the reception staff know who they are, are welcoming, and ensure the client has trust and confidence in the service. If they are attending other services, we can accompany them for the first visit if able or, with permission, contact the provider personally to ensure the client’s wishes and goals are understood and that there is flexibility and understanding if appointments need to be cancelled or changed at short notice.

Can you provide some examples of how the ITC Program has improved health outcomes for clients?

One of my clients wanted to undertake a medical procedure (which they had been strongly advised was necessary for health reasons) but was inhibited by extreme anxiety around some tests required before surgery could be performed. I was able to obtain many extensions to appointments and work with the GP, specialists and day surgery department at the hospital to minimise the client’s anxiety and arrange to be present just prior to and after the procedure. Ensuring the client had adequate time to obtain all the information about the procedure, digest the information, voice their concerns and have them addressed was very helpful and took many months. This preparation allowed for the surgery to take place safely and also helped the client gain confidence that they would be safe during and after the surgery.

As a care coordinator, I have been able to assist clients in the process of obtaining ongoing care and support either through My Aged Care or NDIS. I then help them to develop good, trusting relationships with other care providers and allied health professionals. This can range from supporting clients at the assessments and ensuring their story is heard and individual needs met, to assisting them with changing providers if necessary. This helps clients feel more in control of their health and wellbeing.

NAIDOC Week celebrations are held across Australia each July to celebrate the history, culture and achievements of Aboriginal and Torres Strait Islander peoples. The theme for 2021 – Heal Country! – calls for stronger measures to recognise, protect, and maintain all aspects of Aboriginal and Torres Strait Islander culture and heritage.

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