NACCHO Aboriginal Health : #Healthcarehome ACCHO services starts roll out 1 October 2017


” During the stage one trial, 200 general practices and Aboriginal Community Controlled Health Services in ten regions around Australia will start delivering Health Care Homes services.

Twenty practices will begin Health Care Home services on 1 October 2017. The other 180 will begin on 1 December 2017.

People with chronic and complex conditions, who could benefit from Health Care Homes’ flexible, coordinated care can enrol as Health Care Homes patients “

About Health Care Homes

One in four Australians have at least two chronic health conditions1. For these people, our health system can seem hard to navigate and disjointed. Different health professionals and services work in isolation from each other; care is often un-coordinated; and patients can find it difficult to get to different services and appointments.

A Health Care Home is a general practice or Aboriginal Community Controlled Health Service (ACCHS) that coordinates care for patients with chronic and complex conditions

In an Australian first, 200 practices and ACCHS around Australia will soon begin trialling Health Care Homes. Twenty practices will begin Health Care Home services on 1 October 2017. The other 180 will begin on 1 December 2017.

People with chronic and complex conditions, who could benefit from Health Care Homes’ flexible, coordinated care can enrol as Health Care Homes patients.

A patient who is eligible can choose to enrol, and also chooses a GP – usually the GP they have already been seeing – who knows them, their health conditions and priorities. This doctor leads a care team which will look after that patient.

Together, a patient and their care team will then develop and follow a shared care plan which will:

  • set health goals
  • include strategies to help each patient better manage their conditions and improve their quality of life
  • identify the best local providers who can meet each patient’s needs.

In line with this plan, Health Care Homes will also coordinate that patient’s care. For example, if a patient sees their specialist or goes to hospital, their Health Care Home will follow up. That way, they know about all the care that person receives, both inside and outside the Health Care Home.

Rather than receiving a payment each time a patient has an appointment, Health Care Homes will be paid a monthly payment to care for a patient’s chronic and complex conditions. This flexible funding allows Health Care Homes to be innovative in the way they care for their patients.

Many people with chronic and complex conditions are bulk billed by their GP. Health Care Homes are encouraged to continue to bulk bill enrolled patients. However, it will be up to each Health Care Home to tell patients if they will pay a gap fee.

To find out more about Health Care Homes, go to

Newsletter July Extracts

1.Best-practice examples of chronic disease management in Australia

The aim of this resource is to showcase practical examples of how different clinics across Australia use a variety of patient-centred and best-practice approaches to chronic disease management.

You will find a series of practice snapshots, quotes and case studies, which help illustrate key components of Health Care Homes including:

Download Providers_practice case studies_coordinated carev.2

1.2 Engaging hard-to-reach patients: Aboriginal Community Controlled Health Service

“We see some patients who live in the bush. They have multiple health issues — they are on multiple medications, have limited health literacy, English as a second language, low-socio economic circumstances and are transient.”

“They might come into the clinic for first-aid or for immediate health issues, but they rarely come in for their check-ups or for medication for their long-term conditions.”

“Instead they need to be followed up. We often find that they are not taking their medication, or not in the way it was intended.”

“We have care coordinators — either a registered nurse, an Aboriginal health worker or a staff member — who can case-manage the patient’s care. The care coordinators make sure the patient gets the full level of follow-up required. We also use an electronic recall system as part of the patient notes and have regular meetings to discuss complex patients.”

1.3 Aboriginal Community Controlled Health Service: advanced roles for nurses and Aboriginal health workers

“Our nurses and Aboriginal health workers (AHW) do a lot of case management and palliative care. This includes using telemedicine so that the patients can remain on country if they chose to die, rather than have further treatment.”

“They practice according to the Central Australian Rural Practitioners Association manual and clinical guidelines. These are the best practice clinical guidelines that registered nurses and AHWs follow to diagnose, treat, prescribe medications, order testing and refer patients.”

“They also do INR management, administer thrombolytic therapy and generally manage patients with complex conditions based on the registered care plans created by the doctors.”

“Our GPs oversee the medical management of patients, develop complex clinical care plans for other staff to administer, and review patients as referred by other team members when there are concerns with the management or condition of the patient. So the GPs are kind of like the conductor of the orchestra.”

2. Health Care Homes FAQs June 2017

Download Health Care Homes FAQs June 2017

Extracts Aboriginal Community Controlled Health Services (ACCHS)

 Will ACCHS be able to continue to access the other Commonwealth funding sources if they participate in stage one? If an ACCHS becomes a Health Care Home could they still also receive block funding for primary health care services?

Yes. Participating ACCHS can continue to access grant payments made under the Indigenous Australians’ Health Programme (IAHP), including funding for primary health care activity.

Funding for PHNs to commission integrated team care (ITC) services will also continue at current levels in stage one. An ACCHS which participates in Health Care Homes’ stage one will still be able to tender to provide ITC services.

If participation in the PIP eHealth Incentive (ePIP) is a requirement for practices to apply for Health Care Homes, will this exclude ACCHS if they are not ePIP registered?

All participating practices or ACCHS must register for ePIP before 1 December 2017.

 If patients voluntarily enrol with a participating medical clinic, how will this work for transient patients?

Enrolled patients will still be able to access MBS benefits if they need to see a different health care provider outside their Health Care Home. Transient patients may be able to be treated by a number of Health Care Homes, where a lead Health Care Home would be nominated and manage the distribution of funds accordingly. Such arrangements would need to be negotiated between participating Health Care Homes.

For patients who move between communities and who are not able to nominate and agree to a preferred Health Care Home provider, MBS billing may be more suitable than Health Care Home enrolment.

Are patients who are being care coordinated under the Integrated Team Care (ITC) activity funded by the Department of Health/PHN eligible for Health Care Home services?

Patients receiving care coordination support under an ITC activity who also meet Health Care Home eligibility requirements can be considered for Health Care Home enrolment in stage one. The Health Care Home care planning process will include an assessment of the range of services that an enrolled patient is currently receiving or eligible to access. The resulting care plan and services received should complement and not duplicate the services provided to enrolled patients.


What sort of information will practices need to provide for the evaluation? What KPIs are proposed and will providers be measured on health outcomes, outputs or activities?

Stage one of Health Care Homes will be evaluated to establish what works best for different patients and practices and in different communities with different demographics. The evaluation will need to examine the implementation process as well as the impact of the model. Findings will be used to make refinements to the model before government consideration of any further national roll out.

Health Care Homes will be required to participate in the evaluation by providing data in a number of ways.

The evaluation is not designed to measure the performance of individual practices or providers. Data will be aggregated and then analysed to examine how the model worked in various situations and settings. Practices will provide de-identified patient data from clinical software using an automated extraction process.

An evaluation plan will be developed in 2017. It will include details on the indicators, measures and methods of data collection. It is expected that this will include a range of information on patient and provider experience, practice processes, such as referrals and recording of risk factors, and care provision methods, quality of care and service use. In addition, it is expected to include general clinical indicators, such as blood pressure, BMI or smoking status.

Health Care Home practices will also provide information through surveys and a sample of practices will also participate in interviews or focus groups. These methods will inform the evaluation of the implementation process, types of care provided to patients and changes to practice service delivery model.

As part of the data collection process, information may be fed back to practices to assist them to benchmark their progress against national and regional averages. This information may help practices in their quality improvement activities and may assist PHNs to better target practice support activities. In this case, practice level data would only be seen by the practice itself. Data provided to PHNs would be aggregated across all practices.

What sort of information will patients need to provide for the evaluation?

Patient experience of the Health Care Home model will be a key issue for the evaluation. Patients will likely provide data for the evaluation through participation in surveys, interviews and focus groups.

Patients will also be asked to consent to their de-identified clinical data being extracted from within practice information systems as well as to the linking of their MBS, Pharmaceutical Benefits Scheme and hospital data for the purposes of the evaluation.

Patient participation in data collection for the evaluation will be voluntary.

Will there be a duplicate reporting requirement for ACCHS? For instance, ACCHS who report on National Aboriginal Health Key Performance Indicators (KPIs) using Pencat or Canning Tool?

The department will endeavour to minimise duplication wherever possible. One issue that will require consideration is that reporting on National Aboriginal Health KPIs is done at an aggregate level. In order to measure the effect of the Health Care Home model on patients across time, the evaluator will need to be able to link the data from individual patients across time points, and this is not likely to be possible using data that is aggregated at the practice level. The department will work with the Indigenous sector to determine the best use of available data.

How will reports be required? Electronically? Monthly?

Practices will provide de-identified patient data from clinical software using an automated extraction process. The timing and processes for data extraction, and other methods of evaluation data collection, is currently being considered.  Outside of the evaluation data collection methods, there will be reporting requirements for Health Care Homes regarding enrolment and assurance activities.

3.KPMG report on payment model now available

Following the general advice provided by the ATO, the Department of Health commissioned KPMG to provide further information on the implications of the Health Care Home payment model for participating general practices and Aboriginal and Community Controlled Health Services in relation to their exposure to employment tax obligations.

Download KPMG – Health Care Homes employment tax information

This is now available here in Latest Updates:  more information e-newsletters, fact sheets and booklets

Letters of offer sent out to selected Health Care Homes

Letters of offer, along with program information, are now being sent to selected general practices and Aboriginal Community Controlled Health Services. Participation of selected Health Care Homes will be confirmed when organisations formally accept. Stay tuned.

Check out our Health Care Home resources

For FAQs, fact sheets, case studies and e-newsletters, go to the Health Care Homes for health professionals‘ page then to more information e-newsletters, fact sheets and booklets. Other resources on this page include:

  • Health Care Homes information booklet
  • Minimum requirements of shared care plans fact sheet
  • Payment information fact sheet
  • Patient eligibility fact sheet
  • Stage one modelling fact sheet 
  • Health Care Homes and the quadruple aim
  • Case studies: Best practice examples of chronic disease management
  • E-newsletters — you can subscribe to and see the latest Health Care Homes e-newsletters on the more information page.