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Health Care Homes

In March 2016, the Government announced its plan to introduce stage one of the Health Care Home model in Australia. The following August, NBMPHN was chosen as one of 10 Primary Health Networks across the country, and one of three in NSW, to establish Health Care Homes in General Practice. Over 170 practices and Aboriginal Community Controlled Health Services (ACCHS) around Australia are now providing Health Care Home services to patients with chronic and complex conditions.

In December 2018, the Government has announced the extension of the Health Care Homes program to 30 June 2021 with patient enrolment period extended to 30 June 2019 (or until enrolment reaches 12,000 patients).

The Department of Health hosted a Health Care Homes forum in November 2019 to facilitate further development of the Health Care Homes model and document innovation in a Forum Outcomes Report.

What is Health Care Homes?

A Health Care Home is a home base that will coordinate comprehensive care for patients with chronic and complex conditions.

General practices and Aboriginal Community Controlled Health Services (ACCHS) can serve as Health Care Homes.

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:

  • include comprehensive information about a patient’s care, medications and all the health professionals who care for them
  • identify the local providers best able to meet each patient’s needs, and help coordinate care with these providers
  • include strategies to help each patient better 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 enrolled patients and their carers to be active partners in their care. This will involve giving patients the knowledge, skills and support they need to make decisions about their health and keep healthy.

To enable this new model of care, payments for patients enrolled in Health Care Homes will change.

General Practice’s will be paid bundled monthly payments to provide care for a patient's chronic and complex conditions. This will enable Health Care Homes to be flexible and innovative in caring for enrolled patients. Patients can still use Medicare services for routine care unrelated to their chronic conditions.

The stage one trial of Health Care Homes is expected to run until November 2019.

Health Care Homes Information & Resources

For patients

For GPs and practice staff


FAQs and Case Studies

HCH Funding Model

Payment for services provided under the HCH model is based on a yearly sum that is paid to the primary care provider in monthly instalments. This provides flexibility in funding to encourage a care team approach to chronic condition management. It allows clinicians and patients to work with other providers including specialists, allied health and out-of-hospital services through the use of an individualised care plan to manage the condition.

Australian Association of Practice Management (AAPM) has developed the following guidance for Health Care Homes on building an internal system to record and monitor Health Care Home activities and allocate funds. To download the Health Care Home Activity Monitoring Guide, or more information visit AAPM.

The Health Care Homes funding assurance toolkit assists Health Care Homes staff in developing and implementing policies, procedures and day-to-day activities that support the Health Care Homes funding assurance approach.

The key risk areas which form the basis of the Health Care Homes compliance activities include:

  • incorrect stratification of patients
  • non-provision of Health Care Homes services to enrolled patients
  • systematic double billing under Health Care Homes and Medicare.

MBS items such as care planning, health assessment, mental health planning/ services, telehealth, other clinical services i.e. respiratory function services, wound management should not be claimed for HCH patients.

Health Care Neighbourhood

The Health Care Neighbourhood is the wider health system that the Health Care Home operates within and integrates with.

Creating a team of people to support and care for a patient is at the heart of the Health Care Home model. A central element of the Health Care Homes model is a tailored and dynamic electronic shared care plan that can be accessed by nominated Health Professionals within the care team of a patient.

Each patient enrolled in HCH is managed by nominated GP and supported by the practice HCH team including a care coordinator, nurse and others. The practice team members are actively involved in care coordination and they may be in contact with external healthcare and community service providers. The aim is to facilitate improved communication and coordination of care between the GP practice team and external supports to assist their HCH patients with the navigation of the care system and improve their overall wellbeing.

Integrated and high-performing care teams allow for the distribution of tasks amongst all members of the care team, ensure that they are performing tasks aligned with their skills, knowledge and expertise. This also provides them with the ability to focus on the delivery of patient care that is directly relevant to their role, whether they are a specialist, community pharmacist, allied health or other health care provider.

Allied health professionals are included as vital members of a patient’s health care team. The PHN is working to educate the neighbourhood about the HCH program and help them to enrol in the electronic shared care planning tool. If you are an allied health professional, please download the information pack and contact Maha Sedhom for further information.

HCH Evaluation program

The Australian Government Department of Health has engaged Health Policy Analysis to conduct an evaluation of the Health Care Homes  program. More information can be found in the Health Care Homes Evaluation Plan.

The first Health Care Homes Interim Evaluation Report (2019) is now available. 

Evaluation Guide for Practices

Online Evaluation Application

HCH-A Staff Consensus Tool

HCH Shared Care Planning

A central element of the Health Care Homes model is the development of an individualised electronic Shared Care Plan with the patient. This plan will be implemented by patients care team of providers. The plan will identify the local providers best able to meet each of the patient’s goals and needs (including community pharmacy). Care will be coordinated with these providers, and include strategies to assist each patient manage their conditions and improve their quality of life.

There are several different software providers approved by the Medical Industry Software Association (MISA) that meet the minimum requirements for Shared Care Plans as determined by DoH for General Practice or ACCHS to use. Further information visit Medical Industry Software Association.

HCH Community Pharmacy

The Community Pharmacy in Health Care Homes Trial is an initiative funded through the Pharmacy Guild - to support the incorporation of medication management and reviews by community pharmacists for Health Care Home patients. Pharmacies involved in the trial will work with the Health Care Home team by delivering patient-centred medication management services. Please download the Community Pharmacy in the Health Care Homes information sheet.

For more information visit Pharmacy Guild.

PHN support for registered HCH Practices

NBMPHN provides support to registered Health Care Homes. For general enquiries please contact HCH Practice Facilitator and Support Officers Maha Sedhom on 4708 8100 or online.

Useful Contacts