Health Care Homes

New toolkit for care coordination coming soon

Health Care Homes care coordination toolkit

Chronic disease is on the rise in Australia. One in two Australians now have a chronic disease such as diabetes, arthritis or heart and lung conditions, and one in four have at least two chronic health diseases.

In the South Eastern Melbourne region, Greater Dandenong has high rates of diabetes mellitus, Frankston and Cardinia have high rates of circulatory system diseases, Frankston, Kingston and Mornington Peninsula have high rates of respiratory system diseases and Greater Dandenong,  and  Frankston have very high rates of avoidable mortality from chronic diseases.

Health Care Homes helps people better manage their conditions by giving them coordinated, integrated care, that is tailored to their needs, and is provided at their usual GP clinic. Together with the patient, a care team at the Health Care Home then develops a shared care plan. The aim of this approach is to keep the patient well and out of hospital.

This toolkit has been developed by South East Melbourne Primary Health Network, in conjunction with registered general practice nurses from around the country, to act as your go-to resource.  It has been designed  into easy to access sections so you can access the right information as you need it.

The toolkit for care coordination will be available soon. 

SEMPHN is one of the 10 Health Care Homes trial sites around Australia.

In 2016 the Government announced its plan to introduce stage one of a Health Care Home model to improve care for patients with chronic and complex conditions. It is estimated that about half a million people in South Eastern Melbourne live with one or more chronic health conditions.

The Health Care Homes Stage One is designed to ensure those with chronic conditions receive ‘wrap around’ care, with a local health care team acting as the home base for the patient’s co-ordination, management and ongoing support. Under this model, eligible patients will voluntarily enrol with a participating medical practice known as their Health Care Home.

The Department of Health took applications from interested General Practices and Aboriginal Community Controlled Health Services (ACCHS) late 2016 and the successful applicants were annouced in May 2017. Participating practices will be helping shape a key part of the Australian Government’s health reform agenda.

SEMPHN support

SEMPHN has a team of people with experience in both clinical and management aspects of General Practice. This Health Care Homes Support team is in place to support participating practices to implement Health Care Homes. The HCH team can be contacted via This email address is being protected from spambots. You need JavaScript enabled to view it..

Key links


On 17 November the Department of Health conducted a webcast which included a presentation, as well as a panel answering detailed questions submitted by participants. The one-hour session is recommended viewing and is available here.

Information Sessions

SEMPHN held information sessions for General Practitioners, Managers and Nurses in November and December 2016.

You can look at the Information Session presentation slides here.

You can view a recording of the Information Session (with presentation slides) on Tuesday 22 November here.

Further information sessions will be rolled out once practices have been notified.

Quick help with counting patients

SEMPHN has developed a quick work-around to help estimate chronic disease in your practice by showing you how to count the number of patients with more than one condition.

It's an 8-minute video: Counting Patients with Multiple Chronic Conditions Chronic Conditions that has a step-by-step guide of a manual process using Excel.

The video is about using Excel. All clinical software can extract lists quite easily (for example, Best Practice, Medical Director, POLAR, ZedMed, Doctors Control Panel).

All of these software packages only run reports on an ‘OR’ basis...e.g. patients who have COPD or IHD or Diabetes. You will want to know how many patients have multiple conditions. All the various medical software packages are unable to search on an “AND” basis. ...e.g. patients who have COPD and IHD and Diabetes.

The video suggests a way to use Excel to combine data from various lists so that multiple conditions for the same patient can be counted. One of our team is happy to help your practice with this. Please contact us at This email address is being protected from spambots. You need JavaScript enabled to view it..

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