Project objectives

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.

Australian Department of Health

Our approach

We used quasi-experimental and before-and-after designs and mixed methods to answer the evaluation questions. Our approach included:


  • Periodic surveys of all participating practices and practice staff.
  • Periodic surveys (computer assisted telephone interviews) of a sample of patients and their carers.
  • Case studies of 20 sites (including two Aboriginal Community Controlled Health Service sites) involving site visits and in-depth interviews with practice staff, patients and their carers, and service providers in the health care neighbourhood.
  • Analysis of monthly extracts from clinical management systems of participating practices and comparator practices.
  • Analysis of linked hospital, emergency, MBS, PBS and aged care data for HCH and comparator patients.
  • Analysis of data from the community pharmacies providing medication management services to HCH patients
  • Analysis of program data, which included data from Services’ Australia Health Professional Online Services (HPOS) and data from the risk stratification system.


The 2019 interim evaluation reports helped to improve the trial operations. The 2020 report provided early indicators of practice’s changes in delivering chronic care. The final report will help to inform the future direction of chronic disease management in primary care and other integral pieces of work, such as the Primary Health Care 10-Year Plan.

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