With the Health Care Homes (HCH) pilot underway around Australia, people living with chronic conditions who attend a HCH practice and enrol will have a ‘home base’ for the management of their health in a way that has the potential to deliver more proactive, coordinated team-based care. The HCH is a partnership between the patient, their families and carers, their treating general practitioner and the extended health care team, with an allocated lead clinician, a shared care plan, more support for self-management outside the practice and a bundled payment per with flexibility in how it is used.

Understanding the Health Care Homes Model

The Health Care Homes model was designed to support more coordinated and patient-centred care, particularly for people with complex and chronic health needs. By bringing together healthcare providers and improving care coordination, the model aimed to provide patients with a more connected experience across primary healthcare services.

From the perspective of the Australian health system, the model has four overarching aims:

1. enhance the patient experience
2. improve population health
3. reduce costs
4. improve the work life of health care providers

For general practice there are a couple of particularly exciting elements.

First, funding flexibility. For example, no longer will practices be constrained by only being able to allocate a 5 Medicare-rebateable allied health consultations per care plan. It is possible to allocate more allied health care through the bundled payment in accordance with patient need, if desired. Also, no longer will the GP need to “pop their head around the door” in order to attract a payment when the patient is seeing a primary care nurse, unless it is clinically desirable. Telehealth consultations between a GP (or another clinician) and the practice can also be funded through the bundled payment. The bundled payment can be allocated to where it is of most benefit to the patient! The Department of Health have published some case studies to illustrate this point.

Second, it is worth mentioning that the constant ‘fax out fax in’ paperwork battle that practices are involved in with care planning is no longer necessary this kind of communication can be done online through a software solution.

Third, the software to support the shared care plan. There are a set of minimum requirements for the kind of software that can be used, and to date six companies meet these requirements. The software offer a range of practice and patient supports:

• Create shared care plans that can be viewed and amended in ‘real time’
• Monitor patient compliance with medication regimens and care plans through online systems
• Online patient feedback and satisfaction surveys
• Automatic electronic recalls/reminders
• Send targeted SMS or email campaigns
• Link the software to your usual practice software systems
• Mobile/tablet applications for patients
• Patients can book face-to-face or online video consultations via the internet

Up to 200 general practices and Aboriginal Community Controlled Health Services will participate in stage one of trialling through to the end of 2019.

• Approximately 65,000 patients will participate in the trial (representing 8% of the eligible population living with chronic disease)
• Around 55 patients are expected to enrol per full-time GP
• Current patient estimates:
  • 5% from tier 3 (highest complexity: high risk chronic and complex needs, 1% of population)
  • 45% from tier 2 (multi-morbidity and moderate needs, 9% of population)
  • 46% from tier 1 (multiple chronic conditions, 10% of population)

A fully operational model of clinical services is expected to provide an additional 10% in funding for clinical services above current MBS expenditure for these patients. (This does not include diagnostic imaging performed outside of the Health Care Home, pathology, allied health, specialist services, all of which continue to be available through existing MBS arrangements.) 

A raft of resources continues to be developed to better understand and communicate about the Health Care Homes model. Some examples are provided below.

The Handbook for General Practice and ACCHS Health Care Homes (Dec 2017) includes practice-level information on:

• practice systems (practice readiness and assessment tools; patient identification; enrolment and consent)
• payments
• service delivery
• evaluation
• compliance

Measuring what works: a fact sheet on the evaluation of stage one.

Health Care Homes poster for ACCHS for indigenous patients.

Coordinating Care Around Patient Needs

Effective integrated care requires more than connecting services. Healthcare organisations need to understand patient needs, provider roles, referral pathways, and the barriers that can affect access and continuity of care. Evidence-based health service planning can help organisations design models that respond to these factors and support better healthcare delivery.

Lessons for Future Primary Care Reform

The experience of Health Care Homes provides useful insights into the opportunities and challenges involved in changing primary care delivery. Evaluating implementation, patient experiences, service utilisation, and outcomes can help policymakers and healthcare organisations identify what works and apply those lessons to future primary care reform.