Models of Care
There are various approaches and models taken around the world to care for patients with multiple chronic conditions in the community. General practices are all unique, and no single model is likely to be relevant or applicable to all. Various models of care, ranging in scope and detail, are listed here for reference and inspiration.
Care coordination is a key function of all the chronic disease care models.
The Chronic Disease Management by GP services and allied health (formally known as Enhanced Primary Care) is the current model of care for chronic conditions in Australia. The following is a list of primary care models and recommendations for the Australian context.
- Patient-Centred Medical Home (RACGP Standards)
- Integrated Complex Care
- Recommendations made in the Primary Health Care Advisory Group report: Better Outcomes for people with Chronic and Complex Health Conditions
- A Model for Australian General Practice: The Australian Person- Centered Medical Home (Discussion Paper)
Primary care models from other countries can also be utilized to better understand how to manage and deliver services for patients with chronic conditions.
United States of America
- Patient-Centered Primary Care Collaborative
- Safety Net Medical Home Initiative
- Coach Medical Home
- Guided Care
- Agency for Healthcare Research and Quality - comprehensive practice facilitator modules with resources and tools.
- A practical guide to self-management support - Key components for successful implementation, The Health Foundation, UK (2015)