Health Care Homes

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

Health Care Homes is a model of care for people with chronic and complex health conditions which provides a home base for the coordination and management of their care.

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.

Health Care Homes is a new model for Australian general practice encompassing best practice chronic disease management principles, striving for excellence in quality care systems and a funding model to support the whole of practice integration.

The aim of Health Care Homes is to improve outcomes for people with chronic diseases. This model of care is designed to ensure those with chronic conditions receive ‘wrap around’ care, acknowledging the patient, their family and carers as partners in the care team supported by the team based at the general practice, this team acts as the home base for the patient’s co-ordination, management and ongoing support. The model of care supports and encourages general practice staff to provide person centred care and improve patient self-management through education, support and timely access to appropriate care, reducing unnecessary duplication of services and ultimately improving population health.

Through the Health Care Homes model the General Practices commit to high quality, safe evidence based care appropriate to the patient’s needs, planned around person centred goals, flexible delivery and access.

This model aims to empower Doctors, Nurses, Administration Staff and allied health professionals to work together to support patient centred goals and to improve the scope and skills of the staff will ensure a workforce with improved job satisfaction.

SEMPHN is excited to be facilitating this change.

In the SEMPHN catchment, 24 General Practices are participating in the trial assisted by a dedicated SEMPHN Health Care Homes team in the implementation.

The stage one participant practices are:

  • Baxter Medical and Dental
  • Cabrini General Practice
  • Carrum Downs Medical Centre
  • Casey Superclinic
  • Chandler Road Medical Clinic
  • Dandenong West Medical Centre
  • Dromana Family Doctors
  • First Health Medical Centre – Hampton Park Clinic
  • Hallam Family Practice
  • Headspace Youth Health Clinic
  • Healthmint Medical Centre
  • Lakeside Square Medical Centre
  • Lesdon Ave Medical Centre
  • Lynbrook Village Medical Centre
  • Mackie Road Clinic
  • Mornington Family Doctor
  • Mornington Medical Group
  • Peninsula Family General Practice
  • Star Health – Prahran Clinic
  • Star Health – South Melbourne Clinic
  • Station Street Clinic
  • The First Step Program
  • Thompson Road Clinic
  • Total Care Medical Group

These Practices are being supported to make any necessary changes to their procedures to deliver a practice centered approach. They are developing a community of practice where ideas and challenges are shared. Educational materials are being rolled out nationally (the Modules) and practices will attend SEMPHN specific education sessions to support the patient centered, coordinated model of care.

Future planning for 2018 includes integrating hospitals into the primary care model to further support care coordination and patient centered care.

These participating practices are helping shape a key part of the Australian Government’s health reform agenda.

How are Health Care Homes different?

Current Care  Health Care Home

My patients are those who make appointments to see me

Our patients include those who are enrolled in our Health Care Home and always visit our clinic for complex and chronic disease care
Care is determined by today's problem and time available today Care is planned proactively to meet health needs and patients goals with or without face-to-face visits

Patients are responsible for coordinating their own care

A team of health professionals based at our clinic coordinate all of a patient’s care based on the patients’ needs and goals

It's up to the patient to tell us what happened to them

We plan and track tests and consultations and follow-up hospitalisations to inform future planning for patient care

Practice operations centre on meeting the doctors and the practice financial needs

Our Health Care team works to ensure their skills and knowledge support patients and build a sustainable clinic

SEMPHN support

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

The Health Care Homes team have been providing education events to support practices in the early implementation of the model.

Recordings of the sessions are available to view below:

Shared Care Plan

A central component of the Health Care Home model is a tailored and dynamic shared care plan. The plan is designed to get patients more involved in their own care and improve the coordination of the services they receive inside and outside the Health Care Home.

Together, the patient and the care team at the Health Care Home will develop and use a shared care plan. All Health Care Home patients must have a shared care plan that can be shared electronically between health care providers.

Department of Health fact sheets provide more information.

Care Coordination

Care Coordination is another essential component of the Health Care Homes model. It aims to provide a more organised, more comprehensive and personalised care for a patient.

SEMPHN has developed a Care Coordinators Toolkit to assist care coordinators with providing coordinated patient centered care and self-management support for patients. It contains resources and references to assist general practice Nurses and Health Professionals to improve chronic disease management. The toolkit will be available on this page soon. 

Bundled Payments

To enable this new model of care, payments for patients enrolled in Health Care Homes will change. All general practice healthcare associated with the patient’s chronic conditions be funded through the bundled payment. The monthly bundled payment for participating patients is to reduce paperwork and provide more flexibility in the care provided. Patients can still access fee-for-service billing for care that is not associated with their chronic conditions.

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. Payment values are:

Tier 3 – $1,795 per annum (highest complexity)

Tier 2– $1,267 per annum

Tier 1 – $591 per annum (lowest complexity)

Department of Health fact sheets provide more information


The purpose of the evaluation is to assess the extent to which Health Care Homes is achieving its objectives, and to inform future directions for Health Care Homes in Australia. The Australian Government Department of Health has engaged a consortium led by Health Policy Analysis Pty Ltd to conduct an evaluation of the implementation of the Health Care Homes program.

The evaluation will produce quantitative estimates of the impact of the implementation of Health Care Homes within practices and across practices, and provide qualitative analysis that highlights the factors that are considered important to the success of the program or that present challenges.

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