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Our experienced team supports people across the Wheatbelt with complex and ongoing alcohol and other drug (AOD) and mental health needs, offering integrated medical care, case management, and peer support. This integrated support is designed to improve health outcomes for people living with chronic health conditions through coordinated health care.

About Our Integrated Team Care Program

Holyoake’s team in Northam is part of the Wheatbelt Community Alcohol and Drugs Service (WCADS). We offer integrated medical, counselling and psychosocial AOD support for people with complex needs. This includes co-morbid physical and mental health issues, social dysfunction or AOD use. Our integrated team care program focuses on complex health care needs that often require multidisciplinary care and strong care coordination across health services.

Complementing existing counselling services available through WCADS and access to the Wheatbelt’s Community Program for Opioid Pharmacotherapy (CPOP) program, our integrated approach combines general practitioners, case management, and peer support that helps people:

  • feel more confident in managing their self-management and past or current AOD use
  • understand their health and triggers to understand how to manage chronic conditions 
  • build their life skills and capabilities (with a view to education, work, living independently in the community, etc.)
  • improve their relationships with others and themselves through individual support
  • improve their mood, emotions, sense of well-being, and health outcomes

Many people supported through the program present with chronic conditions such as heart disease or diabetes, highlighting the gap in access to coordinated care.

In the past, I thought going to detox or rehab was the only way to stop drinking. I’m so glad to receive both case management and pharmacotherapy support here. I stopped my drinking with the assistance of medication and counselling.

I’m so grateful for the support that has been provided. I’ve been engaged with many services, and no other service has ever given me the support that I get from this organisation.

How Our Integrated Team Care (ITC) Program Works

Our ITC program aims to ensure quicker access to various services through coordinated, multidisciplinary care delivered by a dedicated team.

Comprehensive & Individual Support For Everyone

  • Complete Medical Support: a GP to provide medical examinations, BBV risk assessments, blood screening, general referrals, and pharmacotherapy support (e.g. Community Program for Opioid Pharmacotherapy [CPOP], medications to treat AOD withdrawal, antidepressants [SSRIs]).
  • Thorough Care Coordination: a Case Manager to help the person we’re supporting action their recovery plan, which will include implementing psycho-educational clinical interventions, assertive follow-ups, and referrals to internal and external service providers.
  • Lived-experience Support: a Peer Support Worker to provide lived-experience and additional support that helps the person re-engage and overcome barriers to intervention. This approach supports culturally-appropriate care as well as culturally safe practices.

Four-Stage Care Coordination

  • Stage 1: Assessment and Recovery Planning. Our team completes our intake assessment with the person who has been referred to us. Eligibility criteria are discussed at this stage to ensure access to appropriate health care and support.
  • Stage 2: Brief Intervention. Our team provides immediate case management support, counselling, peer support or a combination. This helps patients access the right care early and contribute to improved health outcomes.
  • Stage 3: Long-Term Individual Interventions. We provide 12 sessions of individual counselling and group-based interventions, drawing on evidence-based approaches (e.g. CBT, motivational interviewing, relapse prevention, pharmacotherapy). The 12-session limit doesn’t apply to CPOP participants who require ongoing medical care.
  • Stage 4: Program Completion. Once the participant’s agreed goals have been achieved, the program is complete, although we have follow-up procedures in place, if required. Completing the program supports clients to continue living well in the community and reduces the risk of premature death linked to untreated chronic health conditions.

Frequently Asked Questions

Unfortunately, our service is not covered by Medicare. We cannot complete a Mental Health Care Plan or refer to allied professionals (e.g. psychologists, dietitians, physical therapists). We recommend you talk to your GP, as they can discuss referrals through mainstream health services.

Due to the medical guidelines from our GP, we need to complete at least one face-to-face medical assessment before prescribing medications.

No, we cannot prescribe medicinal cannabis.

Integrated care brings together healthcare providers, primary care, specialist services, and community organisations to coordinate care around the patient. We are also committed to delivering culturally appropriate care for Aboriginal and Torres Strait people by working with Aboriginal health organisations and culturally informed strategies.

To make a referral to the Integrated Support team, go to Get Support. You can also contact our team to learn more about the program or review how the integrated team care program supports patients, families, and the wider community.

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