The Health Care Home

Improving care for patients with chronic and complex conditions


The Australian Government recently introduced the stage one trial of a new Health Care Home model to improve care for patients with chronic and complex conditions. The model (based on the U.S Patient-Centred Medical Home model) promotes care that is patient-centred, coordinated, cost-efficient and aimed at achieving agreed long-term health goals.

Under the Health Care Home model, eligible patients will voluntarily enroll with a participating medical practice, which will be known as their Health Care Home. This practice will provide a patient with a ‘home base’ for the ongoing coordination, management and support of their conditions.

While North Western Melbourne PHN is not part of the initial trial of this model, we are deeply committed to supporting general practice to build capacity to adopt this new model of care as it develops.

Our work

North Western Melbourne PHN is currently developing a strategy to work with general practices in the region to prepare for the Health Care Home model.

This activity focuses on supporting general practices in the NWMPHN region to transition to the health care home (HCH) model of care. The aim of the activity is to drive readiness for the future implementation of the health care home model in the region to improve care for people with chronic disease and mental health issues, improving access to care and coordination of care across settings.

The HCH model represents an important innovation for the health system. NWMPHN plans to develop a suite of activities, which include both innovative and more traditional approaches, to support and embed change to improve the efficiency, effectiveness and co-ordination of locally based primary health care services. This plan details a cohesive approach to implementing this innovation within the parameters set out by the Commonwealth.

Key features of a Health Care Home

  • Voluntary patient enrolment: Eligible patients can enrol into the programme and choose a health care provider whose practice becomes the “home base” for the patient, known as a health care home.
  • Central coordination of patient care: The HCH coordinates, manages and supports patient care with the GP leading the care team.
  • Customised shared care plan: The HCH together with the patient, develop a customized and shared care plan for the patient, where they set patient-centred goals, develop care strategies to improve health and identify local care providers to best care for the patient’s needs.
  • Partnership: The patient, the patient’s family and the care team work as partners to motivate the patient to increase their knowledge, skills and confidence to manage their health. New technology will be put to use to further assist patients in ways that are convenient.
  • Better access to health care homes: During the day, patients can access their health care home by phone, email or video conferencing. Access is also available after-hours.
  • Flexible team based care: Team care will support integrated patient care across the whole health care system through shared information and care planning. If a patient is referred to a specialist the health care home follows up to make sure they keep track of everything being done to the patient.
  • Commitment to high quality care: Care givers rely on evidence-based patient health care pathways to plan and decide on how to give the best quality service the patient needs.
  • Monitoring and evaluation: The health care team and the patient collect and share data in order to measure health outcomes and to improve performance.

How can my practice become a Health Care Home?

North Western Melbourne PHN is currently developing ways for practices to start becoming a Health Care Home now. If you are interested in being involved in this initiative, please email