Towards Successful Implementation in Australia

In July 2016, a range of Australian healthcare professionals from universities, general practice, primary health networks, private health, and consumer and professional peak bodies developed principles to guide implementation of the Patient Centred Medical Home (PCMH) model in Australia. These principles cover national and regional leadership (see items 1-8 below), as well as regional and practice-level implementation (items 9-25).

Implementation readiness

  1. Implement a PCMH for all applicable patients, not just those with chronic conditions.
  2. Engage with frontline general practice.
  3. Allow adequate time for planning and preparation prior to implementation.
  4. Measure success against realistic process and outcome goals.
  5. Define and maintain the core elements of the PCMH.
  6. Support adaptiveness for local conditions.
  7. Use Primary Health Networks as key implementation partners.
  8. Build future capacity to sustain the PCMH approach.

Patient-centred care

  1. Develop marketing to establish clear mutual expectations and genuine shared accountability between patients and the PCMH.
  2. Implement the necessary infrastructure and build staff capability to assess care needs and deliver care, through a mix of face-to-face, video, phone and email consultations with all healthcare team members.
  3. Increase the capacity to provide care for underserved populations.
  4. Enable and support patients to be active members of the healthcare team.

Collaborative, comprehensive and coordinated care

  1. Build and fund multidisciplinary healthcare teams that work collaboratively at the full scope of practice.
  2. Include preventive health, and patient life and social issues in care planning and delivery.
  3. Adopt a right-care, right-time approach.
  4. Recognise and work collaboratively within the wider care system.
  5. Build information technology infrastructure and tools to support shared care planning and delivery.

Data-driven improvement

  1. Establish practice-level processes to monitor progress towards becoming a PCMH.
  2. Assess and build on existing capacity to use data effectively for quality improvement.
  3. Focus on building take-up of evidence-based models of care.

Engaged leadership 

  1. Recognise existing leadership and actively invest in building general practitioner leadership.
  2. Invest in building the capacity of the entire practice team to deliver this new model of care.
  3. Establish and communicate a shared vision.

Financing and payment paradigms

  1. Ensure the payment system is designed to support achievement of the PCMH.
  2. Invest in information systems required to monitor and support new payment models.


  1. The George Institute: Patient-centred healthcare homes In Australia: Towards successful implementation [Internet]. Sydney: The George Institute; 2016 [cited March 2017]. Available from: