NACCHO Downloads – Report “Better Outcomes for people with Chronic and Complex Health Conditions “


The current primary health care system is high performing and works well for most Australians. However, in common with a number of developed nations, Australia is experiencing increasing rates of chronic and complex conditions, which challenge our current primary health care system and its connection to secondary care.

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35% of Australians, over 7 million people, have a chronic condition, and an increasing number have multiple conditions, making care more complex and requiring input from a number of health providers or agencies. The Australian Institute of Health and Welfare (AIHW) reported in mid-2015 that approximately 20% of the population have two or more chronic conditions (multiple morbidity)[1].\

This population group has different service needs depending on the level of complexity of their conditions. A risk stratification approach can more effectively support identification of patients with specific needs and target services accordingly Patients with chronic and complex conditions are high users of health services.

Very high general practice (GP) attenders saw three times as many different general practitioners (GPs) compared to low attenders (4.8 compared to 1.5). Just one third (34%) of very high and frequent GP attenders combined saw three to four GPs in 2012-13, while a further 36% of very high and frequent GP attenders saw five or more[2].

Currently, primary health care services in Australia for this patient cohort can be fragmented, and often poorly linked with secondary care services, making it difficult for patients to be confidently engaged in their care as evidenced by the experience of patients that can be found in the Appendices. Most patients with multiple chronic conditions receive treatment from many health providers: most of them working in different locations, and often working in different parts of the health system.

As a result, effective communication between the health ‘team’ can be challenging and may be inconsistent. This leads to concern regarding the quality and safety of patient care.

Submissions to this review also suggest that resources for some patients with chronic and complex conditions could be better targeted to improve quality of care and access, minimise waste and maximise appropriate use of available resources across the whole of the health system.


This report details the evidence for change and recommends broad adoption of a new model of care and supporting reforms to better meet the needs of Australians with chronic and complex conditions into the future. Given the time constraints it has not been possible to cost the model, however the implementation section of the report outlines a staged approach to progressing the model that will include an assessment of affordability.

Central to the proposed reform is the formalisation of the relationship between the patient with chronic and complex conditions and their Health Care Home: a setting where they can receive enhanced access to holistic coordinated care, and wrap around support for multiple health needs.

Key features of the Health Care Home are:

  • Voluntary patient enrolment with a practice or health care provider to provide a clinical ‘home-base’ for the coordination, management and ongoing support for their care.
  • Patients, families and their carers as partners in their care where patients are activated to maximise their knowledge, skills and confidence to manage their health, aided by technology and with the support of a health care team.
  • Patients have enhanced access to care provided by their Health Care Home in-hours, which may include support by telephone, email or videoconferencing and effective access to after-hours advice or care.
  • Patients nominate a preferred clinician who is aware of their problems, priorities and wishes, and is responsible for their care coordination.
  • Flexible service delivery and team based care that supports integrated patient care across the continuum of the health system through shared information and care planning.
  • A commitment to care which is of high quality and is safe. Care planning and clinical decisions are guided by evidence-based patient health care pathways, appropriate to the patient’s needs.
  • Data collection and sharing by patients and their health care teams to measure patient health outcomes and improve performance.

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