Health Care Homes

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Health Care Homes are a transformative reform coming to primary health care in Australia. Stage one of Health Care Homes will begin to deliver services from 1 July 2017 to 30 June 2019 for 65,000 patients within 200 practices across ten geographical regions in Australia.

What is a Health Care Home?

The Health Care Home model offers a more systematic approach to chronic disease management in primary care with a focus on quality and accountability. The model promotes evidence-based, coordinated, multi-disciplinary care to improve efficiencies and promote innovation in primary care. Similar models have been adopted internationally including the United Kingdom and New Zealand.

The approach provides doctors, nurses and other healthcare professionals greater flexibility to shape care around an individual patient’s needs and encourages patients to participate in and direct their own care.

The key values of the model comprise:

  • Patients, families and their carers as partners in their care
  • Voluntary patient enrolment
  • Enhanced access and flexibility
  • Patients nominate a preferred clinician
  • A commitment to care which is of high quality and is safe
  • Team-based care
  • Data collection and sharing

Health Care Homes will register each enrolled patient and monthly payments will be made to the practice on a retrospective basis, to allow for regular patient review of complexity. A single grant of $10,000 will be paid to general practices and Aboriginal Community Controlled Health Services participating in stage one.

A universal patient identification tool will be used to assess patient’s individual needs and risk factors to determine complexity. For example, Tier 3 comprises high risk chronic and complex needs (approx 1% of population); Tier 2 comprises multi-morbidity and moderate needs (approx 9% of population); and Tier 1 comprises multiple chronic conditions, largely self-managing (approx 10% of population.

Introducing Health Care Homes, stage one

Ten regions in Australia have been selected to participate in the first two-year stage of Health Care Homes, to be evaluated prior to national roll out.

In Victoria, the region selected for participation was the South Eastern Melbourne Primary Health Network (SEMPHN) catchment. SEMPHN works on behalf of the Australian Government to improve health care in Bayside, Cardinia, Casey, Frankston, Glen Eira, Greater Dandenong, Kingston, Mornington Peninsula, Port Philip and Stonnington.

The other nine PHN regions selected comprise: Perth North; Northern Territory; Adelaide; Country South Australia; Brisbane North; Western Sydney; Nepean Blue Mountains; Hunter, New England and Central Coast; and Tasmania.

Becoming a Health Care Home

General Practices and Aboriginal Community Controlled Health Services (ACCHS) in the 10 stage one catchments are eligible to apply to become a Health Care Home.

Are you a practice or ACCHS that:

  • Wants to be involved in transformative change to the provision of primary healthcare?
  • Wants to strengthen its patient-centred, coordinated, and flexible care for people with chronic and complex conditions?
  • Has patient cohorts experiencing poor health outcomes due to combination and complexity of conditions and social risk factors who require more targeted support?
  • Is interested in practice-level innovation — broadening the use of technology and the roles of the workforce?

Participation in Health Care Homes will provide your practice or service with:

  • Bundled and flexible payment arrangements for managing your patients with chronic disease
  • Training and support to improve quality and data systems in your practice
  • Access to professional development activities for your practice team
  • A $10,000 one-off grant to assist the establishment of systems to support this initiative.

What is required of a stage one Health Care Home? A general practice or ACCHS participating in stage one will:

  • Be accredited and maintain accreditation, or be registered for accreditation, against the Royal Australian College of General Practitioners Standards for general practices
  • Participate in, or be prepared to participate in, the Practice Incentives Program (PIP) eHealth Incentive
  • Use the patient identification tool to identify the eligible patient cohort in their practice or service, assess individual patient eligibility and stratify their care needs to one of three complexity tiers according to their level of risk
  • Register and connect to the My Health Record system, and contribute up-to-date clinically relevant information to their patients’ My Health Records
  • Ensure that all enrolled patients have a My Health Record
  • Develop, implement and regularly review each enrolled patient’s shared care plan
  • Provide care coordination for enrolled patients
  • Provide care for enrolled patients 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 access for enrolled patients through in-hours telephone support, email or video-conferencing, as well as access to after-hours care where clinically appropriate
  • Collect data for the evaluation of stage one and for internal quality improvement processes.