HealthOne NSW

HealthOne NSW is an integrated primary and community health initiative. It provides capital funding to bring together multidisciplinary teams of general practitioners (GPs) and community health and other health professionals. This capital funding is used to implement a model that supports service integration and coordination. In the model, general practices co-locate or virtually integrate with services from across the Healthcare Neighbourhood. The HealthOne NSW model demonstrates many key features of Patient Centred Medical Homes (PCMHs). (1,2)

Since 2006, NSW has committed more than $45 million in capital funding to develop HealthOne NSW services. A further $3.3 million per annum supports nursing, allied health and service integration positions within HealthOne NSW and other primary and community health services. There are 25 operational service sites across NSW.

The HealthOne NSW program has four key features, five key objectives and four enablers, as shown below.

Key features:
  • integrated care provided by general practice and community health services
  • organised multidisciplinary care
  • care across a spectrum of needs, from prevention to continuing care
  • client and community involvement.  
Key objectives:
  • prevent illness and reduce the risk and impact of disease and disability
  • improve chronic disease management in the community
  • reduce avoidable admissions (and unnecessary demand for hospital care)
  • improve service access and health outcomes for disadvantaged and vulnerable groups
  • build a sustainable model of healthcare delivery.
Key enablers:
  • service and capital planning
  • information and communication technology
  • governance and sustainability
  • workforce development.

Service elements

The goal of HealthOne NSW services is to create a system that delivers integrated, client-focused, multidisciplinary care across a spectrum of needs. To implement this type of care, the program urges local health districts to consider two compulsory service elements and an additional five service elements when designing and developing configurations.

Compulsory service elements

  • Partnerships: At a minimum, HealthOne NSW should have strong links between general practice and community health.
  • Designated communicators: These communicators are important for the operational and clinical aspects of a service. Clients who require a higher level of care coordination should also have a single contact point. Designated communications can be encompassed within a single role or split across several roles. 

Additional service elements

  • Enrolment based on criteria: This enrolment this enables clear identification of the client. Services without a formal enrolment process should have, at a minimum, a system to ensure clients consent to share their health information.
  • Provision of specific services: Examples of specific services include clinics in wound care, foot care, maternal and child health, and immunisations. Additionally, HealthOne NSW can function as a platform for health promotion activities, such as healthy eating and smoking cessation.
  • Case conferencing: This service element provides an opportunity to improve the management of clients with complex needs.
  • Care plan: Any care plan should be agreed in partnership with the client and their multidisciplinary team.
  • Ongoing monitoring: At a minimum, clients who have a care plan will require ongoing monitoring. 

Three broad service configurations have been described for HealthOne NSW services: co-located services, hub-and-spoke, and virtually-integrated services.(1)

For more information about HealthOne NSW, eligibility and the application process, visit the HealthOne website.


  1. NSW Health. Guidelines for developing HealthOne NSW services [Internet]. North Sydney: NSW Health; 2012 [cited March 2017]. Available from:
  2. NSW Health. Improving access to primary care in rural and remote areas (s19(2) exemptions) initiative [Internet]. North Sydney: NSW Health; 2012 [cited march 2017]. Available from: