Closing the Gap Team client base increases from 224 to 405 and our team is striving to provide support services despite no increase in funding

The Closing the Gap Integrated Team Care (ITC) program is an extremely important program for Aboriginal people with chronic health issues, a program and team that Nepean Community and Neighbourhood Services are proud of.

Closing the Gap (ITC) is a program that helps Aboriginal & Torres Strait Islander people in three ways:

  1. Providing financial and physical support to ensure timely access to the medical needs of a person
  2. Cultural support to access mainstream services in a culturally safe and appropriate way
  3. Dedicated Care Coordinators and Outreach workers to assist people in their health journey

The Aboriginal community, and the number of people we support, are increasing dramatically each year. In 2020 Closing the Gap (ITC) had 224 active clients. In 2023 we currently have 405 active clients on our patient register, an increase of 81%. Approximately 300 of our 405 clients are over the age of 50.

To be eligible for this program you must:

  • Have one of the following:
    1. Heart disease
    2. Kidney disease
    3. Respiratory disease
    4. Diabetes
    5. Cancer
  • Be recommended by your GP and have a current GP management plan (dated and signed).

In the 2023 financial year, Care Coordinators from our Closing the Gap team have provided a staggering 31,485 Occasions of Service (eg, coordinating appointments, purchasing medical aids, paying 336 specialist bills in that year), and our Outreach Workers have performed 4854 Occasions of Service (eg. Transport to appointments, home visits, supporting clients at appointments).

With the increasing Aboriginal population in Penrith, as well as the increasing cost of living, the biggest challenge for the team is meeting the financial requirements of the program. The funding provided to pay for specialist appointments, medical aids, transport, allied health appointments, assisted breathing equipment and more, is no longer sufficient to service our clients to the best level, meaning our team need to triage our clients and their needs, to determine the best use of the funds we have.

Funding is essential to make sure we can take the best care of our clients however we are limited with the current funding and ever-growing client list.

Our work makes a big impact on the lives of our clients. I think it is important to hear the stories of our clients who need these often life changing support services.

Paddy Te Tau, Care Coordinator, Closing the Gap talks about the ways the Closing the Gap program has helped her client who suffers from heart disease.

“My client has been on the Closing the Gap books since 2015. He has struggled for most of his life with heart disease and finally had a heart transplant in 2022.

Before he was able to have the heart transplant, he needed to lose a substantial amount of weight. He achieved this through a lot of hard work and diet changes. His weight went down from 140kg to 86kg. Amazing work! He continues to work hard at exercising but does tire quickly. He is also adhering to the new eating regimen. This client has had minor issues with rejection of the new heart, but this has been minimised due to drugs administered to prevent this.

Recovery from this has been long and arduous as the client keeps having fluid build-up in his lungs and has had several admissions to hospital to alleviate this.

To assist with this problem the CTG team is supporting payment to Ripples St Marys for a six-week course of hydrotherapy, which he attends two times per week. At the end of the six weeks, the client will be reassessed to see if he requires further therapy. This exercise therapy will greatly assist the client with his overall recovery while not placing too much strain on his new heart.

The client goes back to St Vincent’s Hospital to see his Cardiologist every fortnight. Our CTG team covers the cost for transport to get the client to and from his appointments as he is too weak to use public transport and is very susceptible to infections that could cause major issues to his health.”  

Belinda Shipley, Aboriginal Health Outreach Worker, Closing the Gap shares a story about a client who was on the heart transplant list but with support managed to get off the transplant list and improve her life quality drastically.

I have worked with a client over a 2-year period who initially lived with her parents and grandparents in a hostile environment. This client was diagnosed with heart disease, had high levels of anxiety, suffered from incontinence, and a poor diet that led to her being overweight. She was put on the heart transplant list.

In a joint approach with Community Health, we were able to reduce her weight, help her achieve independence, gain full time employment and a huge improvement in her health. She is now living on her own and no longer having issues with incontinence. She is now at minimum risk of a heart attack, is off the heart transplant list and has just got engaged!”

Ben Nelson, Aboriginal Health Outreach Worker shares a heart-warming story of a client who received treatment for cervical cancer. “Early in the year one of my clients was diagnosed with cervical cancer. She jumped into treatment straight away, completed chemotherapy and was undergoing radiation to finish off the treatment.

During chemotherapy, she lost her hair, a side effect of this treatment. This caused her a great loss in her self- confidence, and she went into a bout of depression. I briefly suggested the idea of a wig to cover her hair loss until her hair grew back, and she seemed interested. I spoke with NCNS Program Manager, Rodney Matthews and organised a surprise visit to the Penrith Wig Library.

She thought she was going to a regular appointment but to her amazement she was provided a wig that day and could not be happier. She told me the other day that people are stopping to have a chat and complimenting her smile and her joy of life. She has now reconnected and begun repairing relationships with family members that she had not spoken to in several years which has in turn improved her depression.

On the 2nd of November, she had her final radiation session, and all things are looking very positive for this client and her future health.”

These are just a few of our client stories, with many more who have had their health issues supported and lives improved by the Closing the Gap Program. The number of clients is ever increasing, and we will struggle to provide the much-needed support services without review of the current funding. Our team take pride in the work they do and are passionate about being there to support their clients through their difficult health journeys.

Would you like to know more about this program?

Contact our Closing the Gap team on 02 4706 0299 or

Click here to see our Closing the Gap Brochure.

Leave a Reply

Your email address will not be published.

Skip to content