Health Care Homes—Health professionals

This page contains information for health professionals about Health Care Homes.

Page last updated: 04 April 2018

For consumer information, go to Health Care Homes for consumers

Health Care Homes now underway

Almost 200 practices and Aboriginal Community Controlled Health Services (ACCHS) around Australia are now providing Health Care Home services to patients with chronic and complex conditions.

The stage one trial of Health Care Homes will run until November 2019.

The Health Care Home handbook and other resources are available on resources for practices and ACCHS

About Health Care Homes

Health Care Homes are existing general practices or ACCHS which will provide better coordinated and more flexible care for up to 65,000 Australians with chronic and complex conditions.

As noted by the Primary Health Care Advisory Group, chronic disease is on the rise in Australia. One in two Australians now have a chronic disease – such as diabetes, arthritis and heart and lung conditions – and one in four have at least two chronic health diseases1. The Health Care Homes’ model is designed to help Australians better manage their conditions by giving them access to coordinated, integrated care, tailored to their needs.

Inforgraphic illustrating the 'Better Coordinated' Health Care Homes process

Patients who have been assessed as eligible and likely to benefit from this type of care can voluntarily enrol with a participating Health Care Home.

The Health Care Home will develop a shared care plan with the patient, which will be implemented by a team of health care providers. This plan will:

  • identify the local providers best able to meet each patient’s needs
  • coordinate care with these providers
  • include strategies to help each patient manage their conditions and improve their quality of life.

Care will be integrated across primary and acute care as required.

Health Care Homes will support patients and their carers to be active partners in their care, by giving patients the knowledge, skills and support they need to make decisions about their health.

All Health Care Homes have been sent consumer kits in the post. Go to resources for practices and ACCHS and scroll down for soft copy templates of most of these resources, or for information on ordering more hard copy resources.

Inforgraphic illustrating 'Your Care Team' under the Health Care Homes trial

Why is this a priority?

Primary health care services are the first point of contact most Australians have with the health care system. While our primary health care system works well for most people, it does not always meet the needs of people with chronic and complex health conditions.

People with chronic and complex health conditions often need services from different health professionals working in different parts of the system. They can find it difficult to get appropriate care. There can also be poor communication between health professionals and services.

This can cause confusion, delays in service delivery and increase health care costs. It can also put a patient's safety at risk.

By emphasising team-based, coordinated care and better communication, the Health Care Home model can address these issues. Health Care Homes place the patient at the centre of care.

Shared care plan
Bundled payments
How are Health Care Homes different?
Advisory groups

Shared care plan

A central element of the Health Care Home model is a tailored and dynamic shared care plan. During the stage one trial, each Health Care Home patient must have a shared care plan.

Patients, all members of the care team within the Health Care Home and providers outside the Health Care Home can electronically access the shared care plan.

Inforgraphic illustrating 'Your Shared Care Plan' under the Health Care Homes program for easier coordination of your chronic conditions

Many practices and ACCHS around Australia are already using shared care planning tools. A set of minimum requirements for shared care planning software for the stage one trial is available on the shared care plan fact sheet. Health Care Homes can choose any software program that complies with these requirements. The Medical Software Industry Association (MSIA) also has a list of software programs that meet these minimum requirements on its website.

Bundled payments

To enable this new model of care, payments for patients enrolled in Health Care Homes will change. Health Care Homes are paid with a monthly, bundled payment which gives them more flexibility and reduces paperwork.

Each enrolled patient will be registered by the Health Care Home through the Department of Human Services’ (DHS) Health Professionals Online Services (HPOS) system. Regular payments will be made to the practice on a retrospective monthly basis allowing for regular patient review and, if appropriate, adjustment of the patient’s Health Care Home tier level.

There are three levels of payment. The amount paid is linked to each eligible patient’s level of complexity and need, with the highest amount paid for the most complex and high-need patients.

All general practice healthcare associated with a patient’s chronic conditions, previously funded through the MBS, will be funded through the bundled payment.

Enrolled patients can still access fee-for-service billing for care that is not associated with their chronic conditions.

Funding for services provided by allied health professionals and specialists, and for diagnostic and imaging services, are not included in the bundled payment. These services continue to be funded through the MBS. Eligibility for allied health services currently triggered by a GP Management Plan, a Health Assessment for Aboriginal and Torres Strait Islander People or a GP Mental Health Treatment Plan, will be triggered by Health Care Home enrolment.

For more information, go to updates, factsheets and newsletters.

How are Health Care Homes different?

Current care Health Care Home
My patients are those who make appointments to see me Our patients are those who are enrolled in our Health Care Home
Care is determined by today’s problem and time available today Care is determined by a proactive plan to meet health needs, with or without face-to- face visits
Patients are responsible for coordinating their own care A team of health professionals coordinate all of a patient’s care
It's up to the patient to tell us what happened to them We track tests and consultations and follow-up after ED visits and hospitalisations
Practice operations centre on meeting the doctors need Our multidisciplinary team works at the top of our license to serve patients.

Source: Adapted from F.Daniel Duffy, MD, MACP, Senior Associate, Dean for Academics, University of Oklahoma School of Community Medicine

Participating Health Care Homes

Health Care Homes participating practices April 2018 (PDF 402 KB)
Health Care Homes participating practices April 2018 (Word 162 KB)

Advisory groups

To support the implementation of the stage one trial of Health Care Homes, a multi-tiered advisory structure has been established. It consists of an overarching Implementation Advisory Group (IAG) four working groups and a clinical reference group.

The IAG is working with the department, advising on issues relevant to the design, implementation and evaluation of the Health Care Home model. The working groups are guiding the development of core elements underpinning the stage one trial, including payment mechanisms, patient identification, guidelines, training and evaluation. The clinical reference group provides advice on clinical issues related to Health Care Homes.

Adopting the Health Care Homes model was recommended in the final report of the Primary Health Care Advisory Group (PHCAG). This group was established by the former Minister Ley in 2015 to examine improving care and health outcomes for people with complex and chronic conditions.

For consumer information, go to the Health Care Homes for consumers' page.

1 AIHW data release on chronic disease (September 2016). 23 per cent of Australians have two or more of the eight selected chronic diseases in 2014-2015.

Queries about Health Care Homes

Participating Health Care Homes should first contact their PHN practice facilitators with queries about any aspect of Health Care Homes.

Practices can also contact the department on