Community Success Stories




What is Person-Centred Care?

What is Person-Centred Care?

And how it’s helping improve people’s health and wellbeing in Sydney’s Northern area

Person-centred care may well be the future of general practice in Australia, and it’s here now in Sydney’s North. A person-centred care model combines the traditional core values of a family-focused medical practice – providing comprehensive, coordinated, integrated, quality care – that is easily accessible, along with an ongoing, active relationship between the person and their healthcare team.

“Person-centred care focusses on the patient, their needs, and their goals to achieve better health outcomes. It is a team-based approach to healthcare, where the GP works with a team to look after a patient’s welfare and health. This allows health professionals to focus on their skill sets and deliver a better quality of care to patients,” says Sydney local north side GP Dr Kiril Siebert.

Northern beaches patient Meg Parsons was diagnosed with Chronic Obstructive Pulmonary Disease (COPD) – a condition that if not managed properly can have debilitating consequences. Meg’s condition was progressively getting worse and her quality of life was deteriorating.

The moment Meg stepped into a Person-Centred Medical Home (PCMH) practice, she noticed a difference. The receptionist recognised her distress, enabling Meg to be promptly seen by the practice nurse and GP. Meg was adamant she did not want to go to a hospital emergency department. The practice team listened to her health concerns and undertook an immediate course of treatment. The team placed Meg on oxygen, and soon her breathing had greatly improved, alleviating her distress.

As a result of Meg’s visit that day, the practice nurse, Kath Chapman became Meg’s primary contact. Kath referred Meg to the best health services able to assist her in better managing her condition. Passionate GP, Dr Mehrnoosh Alian, now provides an ongoing and preventative approach to Meg’s care.

“You don’t have to be sick to receive care. It can all be a part of your preventative healthcare program. When a person is involved in their own care, they have a better understanding of their own needs. A big part of the person-centred medical concept is the healthcare team supporting each other through this holistic approach. This reduces burnout and makes us all better healthcare professionals,” says Dr Alian.

“We spend time with the patient to work out what they need and what is important to them. We like to make sure they keep the same doctor and nurse and work towards their healthcare goals as a team. In this practice I am in a very lucky position where they allow me to spend time with the patient which is critical. I get to do a full health assessment which can take up to an hour depending on complexity, then we go and talk to the GP together. So, it’s about connecting with and continually touching base with the patient. We get to know them, we spend time with them, we follow-up and connect them to services around the local community to aid them in getting well and staying healthy,” says practice nurse Kathleen Chapman.

The PCMH team empowered Meg to be at the centre of her own care and encouraged her to take proactive steps to manage her condition. Meg was referred to a local hospital to undertake exercise rehabilitation and sent to a specialist physiotherapist who focused on her breathing techniques to build up lung capacity. The team also arranged for an aged care assessment which provided Meg with a home cleaning service. Having this service meant that her home was cleared of dust and she could breathe more easily. Meg was now able to focus on her exercise regime and using a pedometer she could track her steps and improve her fitness.

“I was blown away with how the person-centred care practice helped me. Suddenly my whole world and health improved. I had choices, I was connected to the services I needed, and I could be proactive and in charge of my own health,” says Meg.


“The main benefits of person-centred care are the compassionate nature of the concept, detailed health follow-ups and ability to feedback.”


“A big part of the person-centred medical home program is that the healthcare team supports each other through this holistic approach.”

Practice Nurse

“The patient is always the focus. We are here as a team to assist them. We care about them. We help them on their healthcare journey whether it is about complex health or wellness.”

Sydney North Health Network provides support and education to healthcare teams to help enhance patient experience of coordinated care, improve systems and data collection, optimise health and wellbeing, and improve the work life of healthcare clinicians.

“The person-centred medical home program focuses on important aspects of delivering healthcare – leadership skills, team-based care and provider wellbeing. This comprehensive model of care also provides additional value for patients and prevents burnout of our medical professionals through a shared or team approach,” says Sue Barry from the Sydney North Health Network.

Through this model of care, patients that were previously really isolated in the community now have a place to come and build health-based relationships with our healthcare team and other patients. This is really rewarding. It is about having a team devoted to your care instead of just an individual healthcare professional. It is also about prevention as well as treatment. Whether you are struggling with a number of chronic conditions or reasonably healthy we insist on regularly checking back in with the patient to keep them accountable to achieving their health goals and stay on track with their health outcomes,” reinforces dietician Lisa Mesiti.

Dr Kiril Siebert recently went on a study tour in the USA of general medical practices using the PCMH model of care. Dr Siebert observed general practice teams in the American healthcare system are much bigger than those we have in Australian general practice.

“In the US practice system there is often a doctor, nurse, behavioral therapist, pharmacist, medical assistants and care coordinators all in the one practice. I also noticed that the practices in America rely heavily on their data and how that data is utilised to proactively improve quality of care and used as a benchmark to improve standards. American practices are also not shy to share their data within practices or beyond. In fact, they were very upfront and proud about sharing their data which I think is great and something we could do better here in Australia,” said Dr Siebert.

Dr Siebert was also impressed by one of the American practices that had a ‘Patient and Family Advisory Committee’ or PFAC for short. A PFAC is a committee of 10 patients with whom the practice consults with on health campaigns and utilises for potential practice improvements.

“We met members of this committee and they were really enthusiastic and empowered about the part they played in their own healthcare. I would love to introduce PFACs here in Australia,” says Dr Siebert.

Person-centred care is an example of our ever-evolving health care.

For Meg Parsons, person-centred care has made a world of difference to her life. Meg sums up her experience nicely by saying, “person-centred care makes you feel very important and like you are worthwhile. My care team went through and ticked all the boxes. The caring nature of the concept, detailed health follow-ups and ability to feedback makes it feel like you have an extension of your family to care for you.”


“We all work in a team environment to coordinate and deliver the best care possible to each person.”


“Person-centred care is a team-based approach to healthcare where the GP works with a team to look after a patient’s welfare and health.”

Sydney North Health Network

“The person-centred medical home program focuses on important aspects of delivering healthcare — leadership skills, team-based care and provider wellbeing.”

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