In 2016, the Commonwealth Government announced Perth North PHN as a Health Care Home trial site.  We will be part of a collaborative network of 10 PHN Health Care Home regions sharing information and learnings.

The Health Care Home model aims to improve care for patients with chronic and complex conditions and involves patients nominating a preferred general practice and GP to coordinate their care and this is backed up by data sharing between providers and supporting technologies, such as My Health Record.


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Perth North PHN attended the second Health Care Home training workshop in Sydney last week as part of the Department of Health’s stage one implementation of the Health Care Home model of care. Participants spent two days of problem solving, team work and sharing of practical examples, while gaining tools and resources to support translation of knowledge into general practice.


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As part of the 2017/18 Budget announcements in May 2017, a list of the shortlisted practices were announced.  This list is available on the Health Department website.  Shortlisted organisations are subject to a formal offer, and no legal obligations shall arise unless and until a Letter of Agreement is signed by the Commonwealth.  As part of this announcement, it was advised that 20 practices (across Australia) will commence in October 2017 with the remainder due to commence in December 2017.

Perth North PHN looks forward to working with these practices and will provide ongoing support by dedicated Health Care Home staff members based in our Rivervale Office.



The Department is working closely with Australian General Practice Accreditation Limited (AGPAL) to develop training and education packages for the stage one trial of Health Care Homes. The package includes eleven learning modules explaining the key concepts Health Care Homes practices and Aboriginal Community Controlled Health Services (ACCHS) will need to adopt. The modules incorporate material from three successful evidence-based programs which have been used overseas to transform practices into patient-centred, high performing primary care practices.

Practice facilitators from each of the ten selected PHN regions will undertake intensive training in all of the modules.

AGPAL and the department have developed a handbook for practices outlining the Health Care Homes concept, and resources for patients and the care team.


Patient Enrolment

Enrolling a patient in a Health Care Home will be a new process for practices, doctors and for patients themselves.

The following provides an outline of how enrolment may be undertaken, from an initial consultation about the benefits of the model to a prospective patient, through to registering an eligible patient with the Department of Human Services’ Health Professional Online Services (HPOS). Successful practices will be trained on patient enrolment before enrolment begins in the second half of 2017.

The admissions software and risk stratification tool referred to below are the key resources developed for stage one of Health Care Homes.

Step 1: Eligible patient identified

The practice identifies a potentially eligible patient via:

  • The risk stratification software used by the practice
  • Assessment of a patient during consultation
  • Or if a patient asks about enrolling in Health Care Homes

Step 2: Patient is introduced to Health Care Homes

  • The doctor, practice nurse or other staff member talks to the prospective patient about Health Care Homes
  • The practice gives the patient a brochure about Health Care Homes

Step 3: Risk stratification

  • The Health Care Home completes the second stage of the risk stratification tool for the patient, based on information provided by the patient during the consultation
  • The patient is confirmed as eligible and assessed as either Tier 1, 2 or 3

Step 4: Patient consent

  • The doctor gives the patient an enrolment and consent form, and a patient consent for data provision form
  • The practice gives the patient a resource pack with detailed information about Health Care Home

Step 5: Patient registration 

  • The practice registers the patient with HPOS
  • Bundled payments start from the date the patient is enrolled with the practice


Risk Stratification

To help Health Care Homes target services for people with chronic and complex health conditions, they will all use the same risk stratification tool to identify eligible patients and place them in the appropriate tier.

Precedence Healthcare has won the tender to develop and implement the risk stratification tool and will work with CSIRO on both aspects of this project.

The risk stratification process will help providers identify patients who are eligible to enrol and to assess those patients’ risk factors, including the likelihood of unplanned hospitalisation.

Health care providers will assess the clinical and non-clinical factors that affect their patients’ health.

Patients will be asked for their consent to use their health and personal information for these purposes.


Resources and Newsletters

  • Department of Health, Health Care Home resources are available here.
  • Australian Association of Practice Management, Health Care Home resources are available here.


Webinars now online

  • The Australian Association of Practice Management payment management webinar is available here. The webinar was originally broadcast on 5 December
    • You can read WA Primary Health Alliance General Manager Strategy & Policy, Chris Kane’s detailed notes from the webinar
  • The Department of Health’s Becoming a Health Care Home is also available. The webinar was originally broadcast on 17 November.

For more information visit the Commonwealth’s Health Care Homes website.