Primary health care providers — GP and nurse-run clinics and specialist doctors — are the first point of contact most Australians have with the health care system. While our primary health care system is one of the best in the world, it does not always meet the needs of people with chronic and complex health conditions.
People with chronic and complex health conditions need services from different health professionals working in different locations. Often there is a lack of coordination and communication between the different parts of the system. This can be frustrating for patients, their families and carers. It can also put patient safety at risk and cost the health system more.
The Health Care Home model of care addresses these issues by emphasising team-based, coordinated care and putting systems in place — like the shared care plan — to facilitate communication between all the health professionals who look after a person.
Shared care plan
An electronic shared care plan, tailored to each patient, is an important part of the Health Care Home model. Every Health Care Home patient must have a shared care plan. Patients can access the plan electronically. So can all members of the care team within the Health Care Home; and other health professionals outside the Health Care Home who look after that person.
Many practices and ACCHS around Australia are already using shared care planning software. A set of minimum requirements for shared care planning software is available on the shared care plan fact sheet. Health Care Homes can choose any software program that complies with these requirements. The Medical Software Industry Association (MSIA) also has a list of software programs that meet these minimum requirements.
Health Care Home practices are paid in a new way. They receive a monthly, bundled payment corresponding to the complexity of each patient’s conditions. All general practice healthcare related to a patient’s chronic conditions, previously funded by Medicare fee-for-service payments, is funded through the bundled payment.
The bundled payment gives practices the flexibility to provide the care which patients with chronic conditions need — for example, phone-call follow up with patients, digital health options and nurse-run consultations.
Each Health Care Home patient is registered by their Health Care Home through the Department of Human Services’ (DHS) Health Professionals Online Services (HPOS) system. Payments are made to the practice on a retrospective monthly basis. This allows for regular patient review and, if appropriate, adjustment of a patient’s Health Care Home tier level.
Health Care Home patients can still access fee-for-service billing for care that is not associated with their chronic conditions.
Funding for allied health professionals, specialists, diagnostic and imaging services are not included in the bundled payment. These services continue to be funded through the MBS. A patient’s 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 consumer information, go to the Health Care Homes for consumers' page.