Patient centred medical home principles

Also known as PCMH principles, or 'the principles'.

  • Numerous academic papers discuss patient centred medical home principles, and vary somewhat as to the model's key principles.
  • On this site, we adapt the following Agency for Healthcare Reseach and Quality key principles for the model:
    • patient-centred
    • coordinated
    • comprehensive
    • accessible
    • continuous
    • committed to quality and safety.
  • For more information about the principles of the PCMH model, see the Key principles page.

Patient centred medical home model

Also known as the PCMH model, or 'the model'.

  • The model refers to the use of a primary care medical practice as the hub for a person’s care. As an arrangement of the health system, the PCMH model can be thought of as two integrated parts: the patient centred medical home, and the healthcare neighbourhood (the rest of the health system) it operates within.

Patient centred medical home

Also known as the PCMH , medical home, or 'the home'.

  • The patient centred medical home is a general practice or Aboriginal medical service that has adopted the PCMH principles and model. The medical home includes all members of the practice, including (depending on the practice) the general practitioners, practice nurses, care coordinators, co-located or integrated behaviourists (for example, diabetes educators, dieticians, exercise physiologists, and so on), and administration staff.
  • A PCMH is easiest to envision if its team is co-located. However, as implementation evolves in Australia we will likely see virtual PCMH teams, operating from separate but local sites, and tightly linked through business and communications systems.

Healthcare neighbourhood

Also known as the patient centred healthcare neighbourhood, health neighbourhood, or medical neighbourhood.

  • The healthcare neighbourhood is the wider health system that the PCMH operates within and integrates with. The patient's carer, their PCMH and the additional services they use form their healthcare neighbourhood. In a high-functioning, well-integrated system, the healthcare neighbourhood links to the medical home through regular contact, shared electronic health records, standardised communication practices, in-reach service provision, etc. The healthcare neighbourhood forms part of the care team for a patient when required.

A sample PCMH experience

Sarah has a long-term medical condition. She is largely able to manage her health needs at home by herself, with some support from her carer. Sarah has regular contact with a team of clinicians she has come to know over time. They are part of her patient centred medical home, her first port of call for clinical care support. If needed, this team also helps Sarah coordinate her care and navigate through the health system.

From time to time, Sarah may need to see additional, specialised service providers, for example, mental health, specialised allied health or medical services. Those clinicians are part of Sarah’s healthcare neighbourhood, and they temporarily become part of her clinical care team. This does not mean the patient centred medical home stops being part of her care team. As the hub for Sarah’s healthcare, her PCMH is permanently involved in looking after her healthcare needs. Similarly, if Sarah needs to spend time in a hospital, the community-based services, including the patient centred medical home, remain part of her clinical team.

Health Care Homes

Also known as HCH.

  • In Australia the Commonwealth Government is adopting the term Health Care Homes for a trial beginning July 2017 in selected practices within 10 Primary Health Networks across Australia. Available information at time of publication indicates that there will be considerable overlaps with the patient centred medical home model. Please visit the Department of Health's Health Care Homes website for more information.
  • The Health Care Homes concept focuses on coordination of care, and is limited to patients with specific chronic and complex conditions. Its scope is therefore narrower than the more-inclusive and wider-reaching PCMH model. In this phase of the Health Care Home trials, the government is also trialling an alternative payment model for practices that become a Health Care Home, as defined in the Commonwealth program.
  • Some Primary Health Networks work independently of the Health Care Homes trials. These networks work with general practices, Aboriginal medical services and other services in their regions, to implement elements of the PCMH model.

Integrated care

  • Integrated care entails provision of seamless, effective and efficient care. The care given reflects the whole of a person’s health needs: from prevention through to end of life care; across both physical and mental health; and in partnership with the individual, their carers and family. Integrated care requires greater focus on a person’s needs; better communication and connectivity between healthcare providers in primary care, community and hospital settings; and better access to community-based services close to home.1

Care team

Also known as team-based care or multidisciplinary care.

  • Care teams are professionals from a range of disciplines who work together to deliver comprehensive care, addressing as many of the patient's needs as possible. This care may be delivered by a diverse range of professionals functioning as a team under one organisational umbrella. Alternatively, professionals from a range of organisations, including general practice, are brought together as a unique team. As a patient's condition changes over time, the composition of the team may change as well, to reflect the patient's evolving clinical and psychosocial needs. (2)

Primary Health Networks

  • The key objectives of Primary Health Networks (PHNs) are to: increase the efficiency and effectiveness of medical services for patients, particularly those at risk of poor health outcomes; and improve coordination of care to ensure patients receive the right care in the right place at the right time. Primary Health Networks achieve these objectives by working directly with general practitioners, other primary health care providers, secondary care providers and hospitals, to facilitate improved outcomes for patients. (3)

Multi-Purpose Service Program

  • The Multi-Purpose Service (MPS) Program is a joint initiative of the Commonwealth Government and state and territory governments. It provides integrated health and aged care services for some small rural and remote communities. This allows services to exist in regions that could not viably support stand-alone hospitals or aged care homes.
  • The Multi-Purpose Service Program was developed to provide continuity of care. It also aims to provide a balanced mix of services appropriate to meet local health care needs, and takes into account the limited resources available in a community. The model was developed to to make it possible for rural health initiatives to be funded through pooled arrangements with other programs, such as aged care. These arrangements operate across the Commonwealth and states, to ensure appropriate health and related services are available to small isolated rural communities. (4)


  • A collaborative is a structured program in which participants come together at a series of learning workshops. They hear from experts and from their peers, exchange ideas, share experiences, and learn about practical quality-improvement skills. Between workshops, participants are supported to apply what they learn, to deliver measurable, systematic and sustainable improvements in their care to patients. (5)


  1. NSW Ministry of Health. NSW Integrated Care Strategy [Internet]. North Sydney: NSW Ministry of Health; 2016 [cited March 2017]. Available from:
  2. Mitchell GK, Tieman JJ, Shelby-James TM. Multidisciplinary care planning and teamwork in primary care. Medical Journal of Australia 2008; 188(8):S63.
  3. Australian Government Department of Health. PHN background [Internet]. Canberra: Australian Government Department of Health; 2015 [cited March 2017]. Available from:
  4. Australian Government, My Aged Care. Multi-purpose services for small rural and remote communities [Internet]. Melbourne: My Aged Care; 2016 [cited March 2017]. Available from:
  5. Improvement Foundation. Australian Primary Care Collaboratives [Internet]. Adelaide: Improvement Foundation; 2017 [cited March 2017]. Available from: