Wellness through prevention and management of chronic disease

For an overview of the services we fund for chronic disease, after hours and other services, please download the Summary of Commissioned Services.

Integrated Team Care (ITC)

The Integrated Team Care (ITC) Program is entering a new era to bring you a higher quality of care, closer to you, so you can access the right care, at the right place, at the right time for you.

Western NSW Indigenous residents attending their local AMS to access care for their chronic health condition are provided with care through the ITC Program on-site. 

For more details visit the ITC Program Information page. 


Marrabinya referral form for general practice

Keeping Healthy Puura Manti Program Logo

The WNSW PHN Keeping Healthy Puura Manti Program, formerly known as the Chronic Disease Management and Prevention Program (CDMPP), is a new era following an extensive co-design and consultation process to fill immediate service provision gaps, build the capacity of the Primary Health Care sector for sustainable services, and enhance the integration and coordination of care. 

WNSW PHN has commissioned Marathon Health to deliver the program in the Central West area, while NSW Outback Division of General Practice (NSWODGP) provides the service in the Western NSW area and the Royal Flying Doctor Service South Eastern Section (RFDS SE) is the provider in the Far West.

In addition to this, the program’s Capability Building component across each region is delivered by Prestantia Health.

This Model of Care supports improved management of lifestyle related chronic diseases such as Diabetes, Cardiovascular Disease, Respiratory Disease, Renal Disease, and some Cancers in the general practice setting. The program identifies key components that are necessary to ensure General Practices and patients experience more comprehensive care in the management and prevention of chronic conditions. 

For more information, download a copy of the Fact Sheet.

Outback Eye Service

The Outback Eye Service (OES) is an outreach eye service for patients located in regional NSW. The service is provided in Bourke, Lightning Ridge, Walgett, Brewarrina and Cobar.

The OES provides comprehensive ophthalmic services (ie. primary, secondary and tertiary eye care services) to patients, including:

  • Optometry;
  • Ophthalmology;
  • Eye surgery; and
  • Patient referrals to the Prince of Wales Hospital for complex clinical cases.

Patient clinical services and case management is co-ordinated by the staff of the OES.

The OES is delivered by the Department of Ophthalmology at the Prince of Wales Hospital (as part of the South Eastern Sydney Local Health District) and has a longstanding history in regional NSW, which commenced with the pioneering work of Professor Fred Hollows in Bourke in the 1970s.

For more information please visit their website