Better Outcomes for people with Chronic and Complex Health Conditions


The Primary Health Care Advisory Group provided its final report to Government in December 2015. It examined opportunities for reform in primary health care to improve the management of people with chronic health conditions. The Group noted that “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 full report is available at PHCAG Report.

Further, “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... 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.”

The Advisory Group advocate for the ‘Health Care Home’: “a setting where they can receive enhanced access to holistic coordinated care, and wrap around support for multiple health needs.” According to the Group, the 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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