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.


Latest News

2 November 2018

The second tranche of Health Care Homes began enrolling patients and providing services on 1 December 2017.

These practices are part of a group of up to 200 practices and Aboriginal Community Controlled Health Services (ACCHS) that have become Health Care Homes. The first practices began providing Health Care Homes’ services on 2 October, 2017. The stage one trial of Health Care Homes will run until November 2019.

Participating practices in the Perth North PHN region are:

AHG Super Clinc Midland
Beechboro Family Practice
Brookside Medical Centre
Claremont Medical Centre
Craigie Medical & Dental Centre
DR7 Medical Centre
Hay Street Medical Centre
Highland Medical Madeley
Joondanna Medical Centre
Lindisfarne Medical Group
Mobile GP and Homeless Healthcare
North Beach Medical Centre
Rudloc Road Medical & Dental Centre Morley
Walter Road East General Practitioners
Yanchep Medical Centre



The Department has worked 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 have undertaken 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
  • 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.
  • 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.

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


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 2017
  • The Department of Health’s Becoming a Health Care Home is also available. The webinar was originally broadcast on 17 November 2017

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