Health Care Homes—Health professionals

This page contains information for health professionals about Health Care Homes.

Page last updated: 08 December 2017

For consumer information, go to Health Care Homes for consumers

The second tranche of Health Care Homes began enrolling patients and providing services on 1 December 2017.

These practices are part of a group of up to 200 practices and Aboriginal Community Controlled Health Services (ACCHS) that will this year become Health Care Homes. The first 22 practices began providing Health Care Homes’ services on 2 October, 2017. The stage one trial of Health Care Homes will run until November 2019.

Participating practices are listed here. Additional practices are expected to commence in the coming weeks and the list will continue to be updated.

Resource kits for 1 December practices

All 1 December Health Care Homes will receive consumer kits in the post in early December. Go to resources for practices and ACCHS for soft copy templates, or for information on ordering more hard copy publications.

Health Care Homes underway

Practice Located in the Primary Health Network (PHN)
Paralowie Family Health
Mawson Lakes Medical Centre
The Aboriginal Family Clinic - Noarlunga Centre
The Aboriginal Family Clinic - Clovelly Park
Arkaba Medical Centre
Elizabeth Medical & Dental Centre
Hampstead Health Family Practice
The Health Hub Adelaide
Health Sense Medical Centre
Kingston Family Clinic
Mawson Lakes Healthcare
North East Modbury Medical & Dental Centre
Primary Old Port Road Medical & Dental Centre
Prospect Medical Centre
Salisbury Family Medical Centre
Springbank Medical Centre
Surrey Downs Medical Centre
Tristar Medical Group - Pooraka
Adelaide Primary Health Network, 18 practices
Bertha Street Medical & Dental Centre
Chermside Medical Centre Pty Ltd
Eatons Central 7 Day Family Practice
Family Practice at Kallangur
Kallangur Family Medical Practice
McDowall Village Medical Practice
North Rise Medical Centre
Redcliffe Parade Family Medical Practice
Taringa 7 Day Medical Practice
Wavell Medical Centre
Caboolture Super Clinic
Brisbane North Primary Health Network, 11 practices
Angaston Medical Centre
Clare Medical Centre
Cummins Medical Clinic
Goolwa Medical Centre
Nganampa Health Council Inc. Amata Clinic
Nganampa Health Council Inc. Fregon Clinic
Nganampa Health Council Inc. Iwantja Clinic
Nganampa Health Council Inc. Mimili Clinic
Nganampa Health Council Inc. Pipalyatjara Clinic
Nganampa Health Council Inc. Pukatja Clinic
Norfolk House Medical Centre
Pirie Medical Centre
Lakelands Medical Centre
Tristar Medical Group Keith
Victor Medical Centre
Westlands Surgery
Country SA Primary Health Network, 16 practices
Charlestown Medical and Dental Centre
Andrew Nash Clinic
Appletree Family Practice
Better Health South Tamworth
Central Health Alliance
Dr Yogesh Kalra
Eleanor Duncan Aboriginal Health Centre
Greta Medical Centre
Kariong Medical Centre
Quirindi Health Centre
Tristar Medical Group - Morisset
Tristar Medical Group - Muswellbrook
Warabrook Doctors
Armidale Medical Centre
Windmill Practice
Hunter, New England and Central Coast Primary Health Network, 15 practices
Balance! Springwood Family Practice
Blackheath Family Medical Centre
Bligh Park Family Practice
Derby Street Family Medical Centre
Hawkesbury Family Practice
High Street Family Doctors
Highway 50 Medical Practice
Kable Street General Practice
Katoomba Medical Practice
Lawson Medical Practice
Lower Mountains Family Practice
Penrith Medical Centre
Portland Medical Practice
Upper Mountains Medical Centre
Werrington Country Medical Centre
Nepean Blue Mountains Primary Health Network, 15 practices
Arafura Medical Clinics - Casuarina
Arafura Medical Clinics - Berry Springs Clinic
Arafura Medical Clinics - Fred's Pass
Arafura Medical Clinics - Howard Springs Clinic
Arafura Medical Clinics - Palmerston Clinic
Central Australian Aboriginal Congress Aboriginal Corporation - Amoonguna
Central Australian Aboriginal Congress Aboriginal Corporation - Areyonga (Utju) Clinic
Central Australian Aboriginal Congress Aboriginal Corporation - Mutijulu
Central Australian Aboriginal Congress Aboriginal Corporation - Santa Teresa
Danila Dilba Health Services
Kalkaringi Health Centre, Katherine West Health Board
Lajamanu Health Centre, Katherine West Health Board
Miwatj Health - Gunyangara Health Centre
Miwatj Health - Malmaldhara Health Centre
Miwatj Health - Ngalkanbuy Health Centre
Miwatj Health - Nhulunbuy Health Centre
Miwatj Health - Yirrkala Health Centre
Palmerston GP Super Clinic
Timber Creek Health Centre, Katherine West Health Board
Top End Medical Services - Casuarina
Top End Medical Services Darwin - Stuart Park
Tristar Medical Group Parap
Urapuntja Health Service
Wurli-Wurlingjang Health Service
Yarralin Health Centre, Katherine West Health Board
Northern Territory Primary Health Network, 25 practices
AHG Super Clinc Midland
Ballajura Medical Centre
Bayswater Medical Centre
Beechboro Family Practice
Belridge Medical Group
Brookside Medical Centre
Claremont Medical Centre
Cottesloe Medical Centre
Craigie Medical & Dental Centre
DR7 Medical Centre
GP Superclinic@Midland Railway Workshops
Hay Street Medical Centre
Highland Medical Madeley
Joondanna Medical Centre
Lindisfarne Medical Group
Maylands Medical Centre
Mobile GP and Homeless Healthcare
North Beach Medical Centre
Rudloc Road Medical & Dental Centre Morley
Walter Road East General Practitioners
Yanchep Medical Centre
Perth North Primary Health Network, 21 practices
Bay Street Family Medical Centre
Bayside Medical Group Hampton
Bayside Medical Group Mentone
Cabrini General Practice
Casey Superclinic
Chandler Road Medical Clinic
Dromana Family Doctors
The First Step Program
Frankston Healthcare
Headspace Frankston Youth Health Clinic
Inner South Community Health Service Limited – Prahan
Inner South Community Health Service Limited – South Melbourne
Lesdon Avenue Medical Centre
Mackie Road Clinic
Mornington Family Doctors
Mornington Medical Group
Peninsula Family General Practice
Total Care Medical Group
Carrum Downs Medical Centre
Dandenong West Medical Centre
First Health Medical Centre - Hampton Park
Hallam Family Practice Pty Ltd
Lakeside Square Medical Centre
Lynbrook Village Medical Centre
Pearcedale Medical Centre
Thompson Road Clinic
South Eastern Melbourne Primary Health Network, 27 practices
Brighton Doctors Surgery
Burnie General Practice
Caledonian Medical Centre
City Doctors and Travel Clinic
Claremont Medical Centre
Clarence GP Super Clinic
Deloraine Medical Centre
Derwent Valley Medical Centre
Don Medical Clinic
Glenorchy Medical Centre
Greenpoint Medical Services
Hobart District Nursing Service Inc. (The District Nurses Community Clinic - Hobart)
Hopkins Street Medical Clinic
Kingborough Medical Centre
Launceston Medical Centre
Queenstown General Practice
Rosny Doctors
Rosny Park Family Practice
Sorell Doctors Surgery
Tremaur Medical Centre
Tasmania Primary Health Network, 20 practices
Alpha Medical Centre
Auburn Healthcare Centre
Knightsbridge Medical Centre
Main Street Family Medical Centre
Mt Druitt Medical & Dental Centre
Pitt Street Merrylands Medical Centre
Railway Street Medical Centre
Riverstone Family Medical Practice
Rouse Hill Town Medical Centre
The Hills Medical & Dental Centre
Wentworthville Medical Centre
Bidwill Family Practice
Blacktown Family Medical Centre
Bridgeview Medical Practice
Healthway Medical Practice
Hills Family General Practice
Holroyd Medical Practice
Kings Langley Family Practice
Mt Druitt Medical
Richmond Road Family Practice
Walters Road Medical Centre
Winston Hills Medical Centre
Western Sydney Primary Health Network, 22 practices

About Health Care Homes

Health Care Homes are existing general practices or ACCHS which will provide better coordinated and more flexible care for up to 65,000 Australians with chronic and complex conditions.

As noted by the Primary Health Care Advisory Group, chronic disease is on the rise in Australia. One in two Australians now have a chronic disease – such as diabetes, arthritis and heart and lung conditions – and one in four have at least two chronic health diseases1. The Health Care Homes’ model is designed to help Australians better manage their conditions by giving them access to coordinated, integrated care, tailored to their needs.

Inforgraphic illustrating the 'Better Coordinated' Health Care Homes process

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:

  • identify the local providers best able to meet each patient’s needs
  • coordinate care with these providers
  • include strategies to help each patient 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 patients and their carers to be active partners in their care, by giving patients the knowledge, skills and support they need to make decisions about their health.

Inforgraphic illustrating 'Your Care Team' under the Health Care Homes trial

Why is this a priority?

Primary health care services are the first point of contact most Australians have with the health care system. While our primary health care system works well for most people, it does not always meet the needs of people with chronic and complex health conditions.

People with chronic and complex health conditions often need services from different health professionals working in different parts of the system. They can find it difficult to get appropriate care. There can also be poor communication between health professionals and services.

This can cause confusion, delays in service delivery and increase health care costs. It can also put a patient's safety at risk.

By emphasising team-based, coordinated care and better communication, the Health Care Home model can address these issues. Health Care Homes place the patient at the centre of care.

Shared care plan
Bundled payments
How are Health Care Homes different?
Advisory groups

Shared care plan

A central element of the Health Care Home model is a tailored and dynamic shared care plan. During the stage one trial, each Health Care Home patient must have a shared care plan.

Patients, all members of the care team within the Health Care Home and providers outside the Health Care Home can electronically access the shared care plan.

Inforgraphic illustrating 'Your Shared Care Plan' under the Health Care Homes program for easier coordination of your chronic conditions

Many practices and ACCHS around Australia are already using shared care planning tools. A set of minimum requirements for shared care planning software for the stage one trial is available on the shared care plan fact sheet. Health Care Homes can choose any software program that complies with these requirements. The Medical Software Industry Association (MSIA) also has a list of software programs that meet these minimum requirements on its website.

Bundled payments

To enable this new model of care, payments for patients enrolled in Health Care Homes will change. Health Care Homes are paid with a monthly, bundled payment which gives them more flexibility and reduces paperwork.

Each enrolled patient will be registered by the Health Care Home through the Department of Human Services’ (DHS) Health Professionals Online Services (HPOS) system. Regular payments will be made to the practice on a retrospective monthly basis allowing for regular patient review and, if appropriate, adjustment of the patient’s Health Care Home tier level.

There are three levels of payment. The amount paid is linked to each eligible patient’s level of complexity and need, with the highest amount paid for the most complex and high-need patients.

All general practice healthcare associated with a patient’s chronic conditions, previously funded through the MBS, will be funded through the bundled payment.

Enrolled patients can still access fee-for-service billing for care that is not associated with their chronic conditions.

Funding for services provided by allied health professionals and specialists, and for diagnostic and imaging services, are not included in the bundled payment. These services continue to be funded through the MBS. Eligibility for allied health services currently triggered by a GP Management Plan, a Health Assessment for Aboriginal and Torres Strait Islander People or a GP Mental Health Treatment Plan, will be triggered by Health Care Home enrolment.

For more information, go to updates, factsheets and newsletters.

How are Health Care Homes different?

Current care Health Care Home
My patients are those who make appointments to see me Our patients are those who are enrolled in our Health Care Home
Care is determined by today’s problem and time available today Care is determined by a proactive plan to meet health needs, with or without face-to- face visits
Patients are responsible for coordinating their own care A team of health professionals coordinate all of a patient’s care
It's up to the patient to tell us what happened to them We track tests and consultations and follow-up after ED visits and hospitalisations
Practice operations centre on meeting the doctors need Our multidisciplinary team works at the top of our license to serve patients.

Source: Adapted from F.Daniel Duffy, MD, MACP, Senior Associate, Dean for Academics, University of Oklahoma School of Community Medicine

Advisory groups

To support the implementation of the stage one trial of Health Care Homes, a two-tiered advisory structure has been established. It consists of an overarching Implementation Advisory Group (IAG) and four working groups.

The IAG is working with the department, advising on issues relevant to the design, implementation and evaluation of the Health Care Home model. The working groups are guiding the development of core elements underpinning stage one trial, including payment mechanisms, patient identification, guidelines, training and evaluation.

Adopting the Health Care Homes model was recommended in the final report of the Primary Health Care Advisory Group (PHCAG). This group was established by the former Minister Ley in 2015 to examine improving care and health outcomes for people with complex and chronic conditions.

For consumer information, go to the Health Care Homes for consumers' page.

1 AIHW data release on chronic disease (September 2016). 23 per cent of Australians have two or more of the eight selected chronic diseases in 2014-2015.

Queries about Health Care Homes

Participating Health Care Homes should first contact their PHN practice facilitators with queries about any aspect of Health Care Homes.

Practices can also contact the department on