Australia’s Health Care Homes: laying the right foundations

The Health Care Home is a central component of our national health reforms, and refining the model for broader implementation is essential

It seems a long time since April 2016, when the then federal Health Minister accepted all 15 Primary Health Care Advisory Group recommendations to improve care for Australians with complex, chronic health conditions. Recommendations included a mix of initiatives in system integration, care targeting, outcome measurement, change management and payment redesign.1 Central to this reform was the Health Care Home (HCH) — a change in traditional arrangements between patients and their general practices or Aboriginal community controlled health services.1

The major professional and consumer groups greeted the Minister’s announcement enthusiastically,2-4 and the Council of Australian Governments (COAG) agreed to support from all jurisdictions. The Commonwealth agreed to provide enabling infrastructure to support a national pilot of the HCH model. The states agreed to work with HCHs and Primary Health Networks (PHNs) at local provider level regarding regional planning, collaborative commissioning of services, shared patient information and pooled funding arrangements.5

Under the proposed model, patients will be invited to enrol with a nominated clinician within their practice who will coordinate all their chronic disease management, face-to-face or virtual, within and outside the practice.1 Rather than the myriad Medicare chronic care and planning items currently available for doctors and nurses, practices will receive a single payment of between $591 and $1795 per patient per annum, based on assessment of the patient’s complexity via a risk stratification tool.6 Participating practices will also receive a one-off grant to support training and establishment.6 Practices will be free to work with the patient and family to tailor the care to the patient’s circumstances, clinical need and preference. Opportunities for more innovative use of e-health, both in-hours and after-hours, will be encouraged. Health care — like online banking and shopping — can be uncoupled from traditional in-practice face-to-face delivery, based on patient and clinician agreement.6

The outcomes for 65 000 consenting patients from 200 participating practices within 10 chosen PHN regions will be evaluated over 2 years to determine the impact of the new approach on patient outcomes, hospitalisations and costs;6 in addition, Australia’s remaining 21 PHNs will be encouraged to make HCH-related innovation a priority for their practice development programs.

In November 2016, the Department of Health released HCH expression of interest documentation, including an overview of the COAG-approved model, the process to become involved, and further funding details.6 Final practice selection will occur in the first half of 2017.

Although consumer support for the initiative has been strong,7 professional organisations including the Australian Medical Association8 and the Royal Australian College of General Practitioners9 have voiced concern, against the background of a longstanding Medicare rebate freeze and review of the Practice Incentives Program. Concerns include the size of the payment bundle, recompense for practice change, the urgency to have stage one implemented by 1 July 2017, and the paucity of detail regarding the business costs in moving to the new model.10 The Department of Health has responded with further information regarding payment assumption modelling.11

As the year commences, Australia’s 7000 accredited general practices are considering the risks and benefits of HCH involvement. The initial HCH rollout is described as stage one,11 suggesting that participation in the process would be of benefit for longer term business planning (Box). Practices face difficult choices between the desire to shape the future for their communities, and the business and reputational risks of embarking into the unknown.

So, what are the take-home messages for HCHs in 2017?

COAG has identified the HCH as a central component of our national health reforms, and integral to improved care for the 10% Australians who currently consume 45% of health resources.5 Refining the model for broader implementation in the Australian health care context is therefore vitally important.

International experience suggests that clinician leadership will be critical for success at national and practice levels. Managing change in care delivery, practice innovation and workforce training is challenging, but is pivotal to making our practices and system function better for needy Australians. This change requires active clinician involvement and patient engagement at every stage.12

Finally, engagement in digital transformation is essential to inform and activate our patients, to share personalised care plans across teams, and to collect information to underpin quality improvement and resource allocation.13

We must understand and embrace the commitment of numerous practices, patients and state-funded support initiatives as they test the HCH model. They are allowing us the opportunity to move a valued and heavily used service sector into a future built on service integration, patient engagement and digital change. Working together they will allow us to learn, adapt and upgrade to the COAG HCH of 2018 — progressive, functional and hopefully cyclone proof.