Health Care Home program

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What is a Health Care Home?

A Health Care Home is a medical practice, including general practices and Aboriginal Community Controlled Health Services (ACCHS), which provides a home base for the ongoing co-ordination and management of the health of a person with chronic disease(s).

Eligible patients voluntarily enroll with the participating Health Care Homes medical practice of their choice. The practice assigns a clinician to oversee their care.

Health Care Homes is an Australian Government and Department of Health initiative. It is based on chronic disease management models previously observed in the United Kingdom, United States of America and New Zealand.

The official Commonwealth Government website for the Health Care Homes is:

Vision for Health Care Homes

  • Better-coordinated, more-comprehensive and personalised care
  • Empowered, engaged, satisfied and more-health literate patients, families and carers
  • Improved access to medical care and services, including through appropriate use of non–face-to-face phone and internet-based digital health options
  • Increased continuity and consistent adherence to clinical guidelines
  • Increased productivity of health care service providers
  • Increased provider satisfaction, working to full scope of their license
  • Enhanced sharing of up-to-date health summary information

Key features

The Health Care Homes Program will adopt [1] the recommendations made by the Primary Health Care Advisory Group in its report Better Outcomes for people with Chronic and Complex Health Conditions. Key features of the HCH model are:

  • Voluntary patient enrolment with a practice or health care provider to provide a clinical ‘home-base’ for the coordination, management and ongoing support of patient care. This includes the development of an individualised care plan for patients tailored to their specific conditions and health care needs.
  • Patients, families and their carers as partners in their care where patients are motivated to maximise their knowledge, skills and confidence to manage their health, aided by technology and with the support of a health care team.
  • Patients have enhanced access to care provided by their Health Care Home in-hours, which may include support by telephone, email or videoconferencing, and effective access to after-hours advice or care. Additionally, social prescription and community engagement will be utilised to provide a holistic approach to health care.
  • Patients nominate a preferred clinician who is aware of their problems, priorities and wishes, and is responsible for their care coordination.
  • Flexible service delivery and team based care that supports integrated patient care across the continuum of the health system through shared information and care planning.
  • A commitment to care which is of high quality and is safe. Care planning and clinical decisions are guided by evidence-based patient health care pathways, appropriate to the patient’s needs.
  • Data collection and sharing by patients and their health care teams to measure patient health outcomes and improve performance.

What’s in it for patients?

Patient-centred care with care, treatment and processes based around the patient’s individual needs (see Patient eligibility).

What’s in it for medical practices and health practitioners?

  • Team-based approach to care supports better use of all team members’ skills and can reduce pressure on GPs.
  • Removal of a number of MBS restrictions allows for delegation to other team members who can then function at the top of their scope of practice.
  • Improved coordination of services leads to increased clinical and organisational efficiencies and removes duplication of work.
  • Bundled payments enable practices to align with the model of care and reward value over time rather than volume.
  • Training will be provided to successful Health Care Homes practices in the form of modules and educational resources, including additional information on HPOS.

Stage One rollout

In Stage One, Health Care Homes will be introduced in ten Primary Health Network catchments:

State PHN
New South Wales Hunter New England and Central Coast
Nepean Blue Mountains
Western Sydney
Northern Territory Northern Territory
Queensland Brisbane North
South Australia Adelaide
Country SA
Tasmania Tasmania
Victoria South Eastern Melbourne
Western Australia Perth North

Application to be a Health Care Home

Applications to be a Health Care Home for the Stage One rollout officially opened on 4 November 2016 and closed on 22 December 2016.

Successful applicants

The list of successful applicants is available on the Shortlisted Organisations page.

Participating general practices and ACCHS will receive a one-off grant of $10,000 to support their participation.

Official requirements of a Health Care Home

  • Participate in the Health Care Homes training program.
  • Participate in the Practice Incentives Program (PIP) eHealth Incentive.
  • Use the patient identification tool.
  • Register and connect to the My Health Record system, and contribute up-to-date clinically relevant information to patients’ My Health Record.
  • Ensure all enrolled patients have a My Health Record.
  • Develop, implement and regularly review each patient’s shared care plan.
  • Provide care coordination using a team-based approach.
  • Ensure that all team members have roles which utilise their qualifications and allow them to work to their scope of practice.
  • Provide enhanced in-house access for enrolled patients through in-hours support.
  • Ensure that enrolled patients have access to after-hours care and are aware of how to access after-hours care.
  • Collect data for the evaluation of stage one and for internal quality improvement processes.

For more guidance on the requirements, refer to the Readiness checklist.

Health Care Homes training program

The HCH training program will adopt a ‘train-the-trainer’ approach. PHN trainers will work with HCHs to provide training and ongoing support based on need.

Training for capacity and capability-building will take place over a 12-month period.

The curriculum involves 10 modules delivered through a mixture of seminars/webinars, face-to-face training and self-paced online modules.

HCHs will also be provided with a detailed set of guidelines to complement the training program.

Ongoing support and evaluation

PHNs will provide ongoing support to HCHs.

Technical support will be provided for the patient identification tool and payment mechanism.

All information provided in the evaluation of stage one will inform future roll-out of the model.

An independent evaluator will be contracted to carry out the evaluation.

An important consideration will be ensuring the reporting burden on participating HCHs is minimal.

New payment approach

A new bundled payment approach to the practice will enable practices to develop flexible and innovative team-based approaches to deliver care around the needs of patients with chronic conditions.

Patients are registered through the HPOS system.

There are three (3) payment levels which are linked to each eligible patients’ level of complexity and need. Payments will be made monthly on a pro rata basis.

HCH-enrolled patients can still access normal fee-for-service billing for routine non-chronic disease related care.

Existing MBS items for allied health services remain in place.

Members of a patient's care team for example the General Practitioner or Nurse Practitioner's services will be covered within the bundled payments.