Health Care Homes: for health professionals

This page contains information for health professionals about Health Care Homes.

Page last updated: 09 May 2017

For consumer information, go to Health Care Homes for consumers

What is a Health Care Home?

A Health Care Home is a home base that will coordinate comprehensive care for patients with chronic and complex conditions.

General practices and Aboriginal Community Controlled Health Services (ACCHS) in ten Primary Health Network (PHN) regions around Australia will soon start enrolling Health Care Home patients.

  • Twenty practices will begin Health Care Home services on 1 October 2017. These will be announced soon.
  • The other 180 practices will begin on 1 December 2017.

To see the list of the 200 selected practices, go to the successful grant recipients section on the Tenders and Grants page. These practices are spread across the ten PHN regions of Perth North, Adelaide, Country South Australia, Brisbane North, Western Sydney, Hunter, New England and Central Coast, South Eastern Melbourne, Nepean Blue Mountains, Northern Territory and Tasmania.

Patients who have been assessed as eligible and likely to benefit from this type of care can voluntarily enrol with a participating Health Care Home.

The Health Care Home will develop a shared care plan with the patient, which will be implemented by a team of health care providers. This plan will:

  • identify the local providers best able to meet each patient’s needs
  • coordinate care with these providers
  • include strategies to help each patient better manage their conditions and improve their quality of life.

Care will be integrated across primary and acute care as required.

Health Care Homes will support enrolled patients and their carers to be active partners in their care. This will involve giving patients the knowledge, skills and support they need to make decisions about their health and keep healthy.

To enable this new model of care, payments for patients enrolled in Health Care Homes will change.

Health Care Homes will be paid bundled monthly payments to provide care for a patient's chronic and complex conditions. This will enable Health Care Homes to be flexible and innovative in caring for enrolled patients. Patients can still use Medicare services for routine care unrelated to their chronic conditions.

Image of a health care professional talking to a patient

Why is this a priority?

Primary health care services are the first point of contact most Australians have with the health care system. While our primary health care system works well for most people, it does not always meet the needs of people with chronic and complex health conditions.

People with chronic and complex health conditions often need services from different health professionals working in different parts of the system. They can find it difficult to get appropriate care. There can also be poor communication between health professionals and services.

This can cause confusion, delays in service delivery and increase health care costs. It can also put a patient's safety at risk.

By emphasising team-based, coordinated care and better communication, the Health Care Home model can address these issues. Health Care Homes place the patient at the centre of care.

Shared care plan
Bundled payments
If a practice is not registered for ePIP can they still become a Health Care Home?
How are Health Care Homes different?
Advisory groups
More information e-newsletters, fact sheets and booklets


Over $110 million in government funding is being provided for Health Care Homes. This includes $21.3 million to implement and evaluate the Health Care Home model. An additional $93 million in Medicare Benefits Schedule (MBS) funding is being redirected for clinical service delivery.

Participating general practices and ACCHS will also receive a one-off grant of $10,000 (GST exclusive) to support their participation.

Shared care plan

A central element of the Health Care Home model is a tailored and dynamic shared care plan. During the stage one trial, each Health Care Home patient must have a shared care plan.

Patients, all members of the care team within the Health Care Home and providers outside the Health Care Home can electronically access the shared care plan.

Many practices and ACCHS around Australia are already using shared care planning tools. The department has developed a set of minimum requirements for shared care planning software for the stage one trial. Health Care Homes can choose any software program that complies with these requirements. To assist practices and ACCHS, the Medical Software Industry Association has compiled a list of software programs that meet these minimum requirements which is available from its website

Bundled payments

The Health Care Home approach moves away from traditional fee-for-service billing to a bundled monthly payment to the practice.

Removing traditional fee-for-service billing will better support flexible and innovative team-based approaches to deliver care around the needs of patients.

Each enrolled patient will be registered by the Health Care Home through the Department of Human Services’ (DHS) Health Professionals Online Services (HPOS) system. Regular payments will be made to the practice on a retrospective monthly basis allowing for regular patient review and, if appropriate, adjustment of the patient’s Health Care Home tier level.

There are three levels of payment. The amount paid is linked to each eligible patient’s level of complexity and need, with the highest amount paid for the most complex and high-need patients.

All general practice healthcare associated with a patient’s chronic conditions, previously funded through the MBS, will be funded through the bundled payment.

Enrolled patients can still access fee-for-service billing for care that is not associated with their chronic conditions.

Funding for services provided by allied health professionals and specialists, and for diagnostic and imaging services, are not included in the bundled payment and will continue to be funded through the MBS. Eligibility for allied health services currently triggered by a GP Management Plan, a Health Assessment for Aboriginal and Torres Strait Islander People or a GP Mental Health Treatment Plan, will be triggered by Health Care Home enrolment.

For more detailed information, refer to the Health Care Homes information booklet and to the payment factsheet.

If a practice is not registered for ePIP can they still become a Health Care Home?

All services participating in the stage one trial of Health Care Homes will be required to register and connect to the My Health Record system, and contribute up-to-date clinically relevant information to their patients’ My Health Records. All enrolled patients will have a My Health Record. If they do not have one, the Health Care Home must assist the patient with enrolment.

Because of this requirement, to be eligible for the stage one trial, practices or ACCHS need to be participating in, or prepared to participate in, the Practice Incentives Program (PIP) eHealth Incentive. Those not currently participating in ePIP must register. More information about the Practice Incentives Program eligibility requirements can be found on the DHS website.

Once the eligibility criteria for participation are met, your organisation will need to complete the registration process through DHS’ HPOS system.

How are Health Care Homes different?

Current care Health Care Home
My patients are those who make appointments to see me
Our patients are those who are enrolled in our Health Care Home
Care is determined by today’s problem and time available today
Care is determined by a proactive plan to meet health needs, with or without face-to- face visits

Patients are responsible for coordinating their own care

A team of health professionals coordinate all of a patient’s care

It's up to the patient to tell us what happened to them
We track tests and consultations and follow-up after ED visits and hospitalisations

Practice operations centre on meeting the doctors need
Our multidisciplinary team works at the top of our license to serve patients.

Source: Adapted from F.Daniel Duffy, MD, MACP, Senior Associate, Dean for Academics, University of Oklahoma School of Community Medicine

Advisory groups

To support the implementation of the stage one trial of Health Care Homes, a two-tiered advisory structure has been established. It consists of an overarching Implementation Advisory Group (IAG) and four working groups.

The IAG is working with the department, advising on issues relevant to the design, implementation and evaluation of the Health Care Home model. The working groups are guiding the development of core elements underpinning stage one trial, including payment mechanisms, patient identification, guidelines, training and evaluation.

For more information about IAG members, refer to the IAG page.

Adopting the Health Care Homes model was recommended in the final report of the Primary Health Care Advisory Group (PHCAG). This group was established by the former Minister Ley in 2015 to examine improving care and health outcomes for people with complex and chronic conditions. For more information, refer to the PHCAG page

For consumer information, go to the Health Care Homes for consumers page.