Building multidisciplinary care in Hume – the Health Care Neighbourhood Project

As part of the Australian Government’s Strengthening Medicare reforms, primary health networks across the country are building multidisciplinary care teams to deliver high-quality continuity of care to address people’s health needs.

With funding from the Australian Government Department of Health, Disability and Ageing, North Western Melbourne (NWMPHN) has commissioned multidisciplinary care from allied health professionals and general practices to improve the health of under-served patients.

Known as the ‘Health Care Neighbourhood Project’, activity is focused on the Hume local government area, where residents are particularly at risk. Rates of chronic disease are high, and residents are frequently hospitalised and present at emergency departments due to chronic conditions.

NWMPHN has commissioned four general practices and a ‘neighbourhood care team’, comprising a care coordinator and a social worker who will provide care coordination and support for the practices.

NWMPHN is working with the commissioned providers and patient representatives to co-design a model that best suits each practice’s ways of working and patient cohort.

The project aims to:

• strengthen the capability of primary care providers to deliver multidisciplinary care
• improve patient care by designing and delivering multidisciplinary care in general practice.

The project’s intended long-term outcomes are:

• Participating general practices and allied health providers develop their capability, and the utility of the model of care is sustained after the life cycle of the project.
• There is a broader acceptance that the multidisciplinary model of care developed through the project is a good way of working and integrated into general practice.
• The improvements in chronic disease management are sustained (by primary care providers and patients), leading to better patient outcomes, reduced hospital admissions and improved integration.

Paged updated 10 July 2025