Health Care Homes (HCH) ran from October 2017 to June 2021 as a trial in selected general practices and Aboriginal Medical Services (including ACCHOs) from 10 PHN regions across Australia. HCH is a variant of the patient-centred medical home, which aims to improve the effectiveness of primary care. Features of the program included:
- Voluntary enrolment of patients to a practice—their health care home—nominating a GP as their preferred clinician.
- Tools to identify patients at risk of hospitalisation and stratify them to a complexity tier.
- A bundled payment for every enrolled patient based on their tier (for services relating to the patient’s chronic conditions), replacing the Medicare fee-for-service payment.
- Patient access to medication management services by a community pharmacy of their choice, and a bundled payment to the pharmacy for these services.
- Training resources to support transformation of practices towards a HCH model.
- Support for practices to undertake transformation, provided by PHN practice facilitators.
- Shared care planning, giving authorised health professionals access to an up-to-date electronic medical record for each enrolled patient.
The evaluation aimed to assess the implementation and early outcomes of the model, including barriers and enablers of implementation, changes to chronic disease management in general practice and effects on patient experience, patient self-management, quality of life, and reducing emergency department attendances and hospital admissions.