Health Care Homes

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

In 2016 the Government announced its Health Care Home trial to improve care for patients with chronic and complex conditions. Health Care Homes offers a model of care for people with chronic and complex health conditions which allows a General Practice or Aboriginal Community Controlled Health Service (ACCHS) to be a home base for the coordination and management of a patient’s care.
It is estimated that about half a million people in South Eastern Melbourne live with one or more chronic health conditions. In December 2018, the Health Care Homes program was extended to 30 June 2021.

The aim of Health Care Homes is to improve outcomes for people with chronic diseases. The model of care aims to ensure those with chronic conditions receive ‘wrap around’ care. The patient, their family and carers are partners in the care team supported by the general practice team. The Health Care Home is the 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 to improve patient self-management through education, support and timely access to appropriate care, reducing unnecessary duplication of services and ultimately improving population health.

The Community Pharmacy in Health Care Homes Trial is an additional initiative to support the incorporation of medication management programs within Health Care Homes. Pharmacies involved in the trial will work in conjunction with the Health Care Home teams by delivering patient-centred medication management services.
In the SEMPHN catchment, 16 General Practices are participating in the trial assisted by a dedicated SEMPHN Health Care Homes team in the implementation.

Shared Care Plan

A central component of the Health Care Home model is a tailored and dynamic electronic 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 Health Care Home develop an electronic shared care plan that is then shared with the wider health care team. The wider health care team is any health professional directly involved in the patient's current care and they have access to contribute to the shared care plan. 

Health Care Homes in action


Key links

Department of Health fact sheets provide more Health Care Homes information.
Get a general overview of Health Care Homes here.
Health Care Homes team handbook can be found here.
Find out more about the Health Care Homes Community Pharmacy trial here.
Find out more about the evaluation of Health Care Homes here.
To contact the SEMPHN HCH team email This email address is being protected from spambots. You need JavaScript enabled to view it.

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